Section 10 Flashcards
A 60-year-old woman presents to the office following a thalamic stroke nine months ago. Since her stroke, she complains of diffuse burning pain that is worse in her extremities. She reports significant fatigue and sensitivity to temperature. She denies loss of muscle strength. She has been treated with amitriptyline without relief. Her physical exam is significant for hypersensitivity to light palpation of her skin. What is the best next step in the management of this patient?
1. Continue amitriptyline and add tramadol
2. Continue amitriptyline and add gabapentin
3. Discontinue amitriptyline then perform motor cortex stimulation
4. Discontinue amitriptyline then perform brain stimulation
2. Continue amitriptyline and add gabapentin
- This patient has central pain syndrome. There is strong evidence for the use of tricyclic antidepressants such as amitriptyline, SNRIs such as duloxetine or venlafaxine, and the anticonvulsants pregabalin and gabapentin. There is moderate evidence for the use of tramadol or an SSRI and weak evidence for using S-adenosyl-L-methionine (SAMe).
- Gabapentin can alleviate chronic pain in select patients with centralized pain, particularly those with peripheral neuropathy.
- According to a 2015 review of the effects of gabapentin on central stroke-related pain, over 50% of patients in the study had clinically significant pain improvement with gabapentin.
- Motor cortex stimulation (MCS) and deep brain stimulation (DBS) are effective treatment modalities for patients with refractory pain, centralized pain, and peripheral neuropathy.
A 35-year-old female patient presents to the clinic with complaints of irregular menstrual cycles and a thick yellowish fluid oozing out of her breasts. She is sexually active and has been married for four years, but for no known reason, she is unable to get pregnant. The rest of the physical examination is unremarkable. The thyroid function tests are within a normal range, and the serum prolactin level is 1200 ng/ml (4.8 to 23.3 ng/ml). MRI shows a 2.0 cm pituitary mass. Which of the following drugs is used to treat this pathology?
1. Cabergoline
2. Synthetic thyroid hormone
3. Selective serotonin reuptake inhibitors
4. Oral contraceptives
1. Cabergoline
- Treatment of hyperprolactinemia depends on the cause. Once the physiological cause of hyperprolactinemia is excluded, one should look for other possible systemic causes and address them for symptomatic patients.
- Treatment is only necessary if patients develop hypogonadism, osteoporosis, or troublesome galactorrhea. If hyperprolactinemia is suspected because of drugs, it should be discontinued temporarily, if possible, to see if the prolactin level normalizes. If medication cannot be discontinued, especially antipsychotics, it should be changed to a different antipsychotic agent that does not increase prolactin, e.g., quetiapine. If that is not possible, the addition of dopamine agonists should be considered. These changes should be made in consultation with a psychiatrist. The addition of estradiol in women and testosterone in men can be considered for hypogonadism and low bone mass. If the prolactin level does not normalize after stopping medication or if discontinuation of medication is not possible, pituitary MRI should be done.
- Endocrine society guideline recommends against treatment with a dopamine agonist for asymptomatic microadenoma but recommends dopamine agonist therapy to decrease prolactin levels and tumor size and normalize gonadal function for symptomatic patients with microadenomas or macroadenomas. Cabergoline is preferred to other dopamine agonists due to its higher efficacy in normalizing prolactin levels and tumor shrinkage.
- Most prolactinomas are treated with medical therapy only. Surgery and radiotherapy are reserved for those who are resistant to medical therapy with dopamine agonists. Endoscopic endonasal transsphenoidal surgery is a preferred surgical method. Prophylactic surgery is considered in women with large prolactinomas, which potentially threatens vision during pregnancy.
A 15-year-old boy is brought to the emergency department with complaints of progressive headache and multiple episodes of projectile vomiting 5 months after the revision of a hydrocephalus shunt. The patient has optic disc edema. The shunt chamber does not recoil following its manual compression. There is poor CSF flow during a diagnostic shunt tap. Which of the following is the most likely etiology for the clinical deterioration observed in this patient?
1. Distal shunt failure
2. Proximal catheter obstruction
3. Meningitis
4. Peritonitis
2. Proximal catheter obstruction
- The patient has features of raised intracranial pressure such as headache, vomiting, and optic disc edema. Shunt obstruction is a common complication associated with shunt placement.
- There is evidence of proximal shunt failure resulting in its obstruction since there is no recoil of the chamber following its manual compression.
- The poor CSF flow during diagnostic shunt tap has more than 90 percent positive predictive value in diagnosing the condition.
- The distal catheter obstruction will show difficulty in compressing the valve following its recoil and occluding the proximal catheter. Shunt infection and meningitis present with high-grade fever, nuchal rigidity, and altered sensorium. In the case of peritonitis, there will be features of rebound abdominal tenderness.
The nurse mishears the order for “2 and 50” and instead gives 250 mcg of fentanyl. Two minutes later the oxygen saturation is 80 percent. What should be administered first?
1. 0.4 mg flumazenil
2. 0.4 mg naloxone
3. 0.5 mg atropine
4. Oxygen
4. Oxygen
- This patient is experiencing opioid-induced respiratory depression from a large fentanyl dose.
- While reversal with naloxone may be required, oxygen should be administered first.
- Along with oxygen administration, attempts to arouse the patient and open the airway should be performed.
- Failing these maneuvers, reversal may be required.
A 45-year-old man patient presents to the clinic following progressive headache and diminution of vision. Visual field study reveals the presence of bitemporal hemianopia in the patient. MRI reveals giant pituitary macroadenoma with suprasellar extension. An endoscopic endonasal trans-sellar excision of the tumor is planned. Intraoperatively, while trying to remove the tumor on the cavernous wall, there is a sudden jet of blood into the operating field. The operating surgeon controlled the bleeding with rigorous packing with hemostatic agents into the cavernous wall. The remaining portion of the tumor is removed. In the postoperative period, the patient complains of severe headaches. The patient also develops ptosis with ophthalmoplegia. He further develops progressive painful proptosis. Which of the following is the next best step in the management of this patient?
1. MR angiography
2. CT angiography
3. Stereotactic radiation
4. Digital subtraction angiography (DSA)
4. Digital subtraction angiography (DSA)
- The patient has developed vascular cavernous sinus syndrome owing to the injury to the cavernous portion of the internal carotid artery.
- The characteristic syndrome in the patient is most likely following either rupture of the pseudoaneurysm or the development of the direct carotid-cavernous fistula in the patient.
- The digital subtraction angiography is diagnostic as well as therapeutic in the patient. The embolization of the pseudoaneurysm or the placement of the pipeline flow diverters can be undertaken in the case of carotid-cavernous fistula.
- The MR or CT angiography is only of diagnostic value. The stereotactic radiation is justified in limited cases of such vascular complications, especially in a patient who fails endovascular procedure. The clinical benefits are seen after a considerable period of time only, and the patient also has a high risk of recurrence.
A 45-year-old female is seen in the outpatient clinic due to the incidental finding of a 1.7 cm x 1.9 cm isodense left lateral ventricle mass seen on the head computed tomographic scan with contrast done for workup for chronic sinusitis. On magnetic resonance imaging, the mass is located adjacent to the choroid plexus of the atrium of the left lateral ventricle and is isointense to gray matter on T1/T2 and has homogenous/vividly enhancing on post-contrast images. Also, there is evidence of fine calcified borders on the gradient echo sequence. No evidence of hydrocephalus or parenchymal edema is seen. On the physical exam, the patient is neurologically intact and only complains of a bifrontal headache. What is the best next step in management?
1. Consult neurosurgery for an urgent operation
2. Observation
3. Radio-oncologist consult for elective radiosurgery
4. Obtain serum beta-human chorionic gonadotropin, alpha- fetoprotein, and placental alkaline phosphatase
- Consult neurosurgery for an urgent operation
2. Observation - Radio-oncologist consult for elective radiosurgery
- Obtain serum beta-human chorionic gonadotropin, alpha- fetoprotein, and placental alkaline phosphatase
- Meningiomas are usually isointense to grey matter (60-90%) on T1 and T2 sequences. Intraventricular meningiomas are mainly benign, slow-growing lesions. However, it is important to follow- up with serial imaging due to the risk of ventricular trapping and symptomatic parenchymal edema that may warrant surgical intervention.
- Meningiomas appear more common in the atrium on the left lateral ventricle and are well-circumscribed, homogeneously enhancing masses.
- Compared to extra-axial meningiomas, intraventricular meningiomas have a higher percentage of calcification (50 vs. 20%).
- Due to the absence of hydrocephalus, choroid plexus papilloma is unlikely. Due to the absence of adjacent brain parenchymal edema, choroid plexus carcinoma and brain metastasis are unlikely. There is no need for urgent surgery or radiosurgery.
A 17-year-old female, with no comorbidities, is brought to the emergency department with a history of a motor vehicle accident involving a car (which she was driving) and a bus, one hour back. On examination, her pulse rate is 80/minute, blood pressure 130/80 mmHg, respiratory rate 16/minute, and oxygen saturation is 98%. Her airway is clear, and air entry is bilaterally equal in all lung fields. Her Glasgow Coma Scale (GCS) score is E3V4M6, and her pupils are bilaterally 3 mm in size and react to light. A chest X-ray taken shows clear lung parenchyma. A computed tomogram scan of the brain is taken, which shows an undisplaced right frontal bone fracture and an underlying contusion of 15 ml volume. There is no midline shift or mass effect. She is admitted to the neurosurgery intensive care unit. Two hours later, the patient develops tachypnea (respiratory rate of 30/minute), while GCS score and pupils remain the same. Within 2 minutes, her saturation drops down to 80%, and she has to be intubated and ventilated. On chest auscultation, there are bilateral basal crackles. A chest X-ray shows bilateral hyperdense infiltrates in the lung parenchyma. Which part of the brainstem is likely to contribute to the current deterioration in her clinical condition?
1. The dorsolateral aspect of the pons
2. The ventrolateral aspect of the pons
3. The dorsolateral aspect of the medulla
4. The ventrolateral aspect of the medulla
4. The ventrolateral aspect of the medulla
- The patient has neurogenic pulmonary edema. Rapid developments characterize the early stages of neurogenic pulmonary edema. The patients are usually children or young adults who have suffered an intracranial injury recently.
- The clinical signs boil down to classic signs of pulmonary edema with the absence of signs of left ventricular failure usually found in cardiogenic edema.
- Although for classic neurogenic pulmonary edema, the manifestation could be detected clinically within 2 to 12 hours post-injury; presentation may take days in some cases.
- Area A1, situated in the ventrolateral aspect of the medulla, is one of the main trigger centers for neurogenic pulmonary edema. It is composed of catecholamine neurons that project to the hypothalamus.
A 65-year-old male with a past medical history of atrial fibrillation on warfarin and metoprolol, gastroesophageal disease, and type 2 diabetes on metformin presents to the emergency department after the onset of word slurring and left facial droop 3 hours ago. He is still unable to articulate a complete sentence. After a comprehensive neurologic exam and imaging, an area of decreased perfusion is found in the territory supplied by the middle cerebral artery, and tPA is administered. The patient’s symptoms partially improve. Several hours after treatment, the patient develops worsening confusion and arm weakness. Repeat computed tomography scan shows a new large area of increased attenuation in the lateral parietal lobe. What is the appropriate next step?
1. Repeat tPA
2. Computed tomography scan with IV contrast
3. Neurosurgical intervention
4. Magnetic resonance angiogram
3. Neurosurgical intervention
- Post-tPA intracranial hemorrhage should be considered if the patient develops a worsening neurologic exam, new headache, change in the level of consciousness, increased weakness, or sudden change in blood pressure. Risk factors include older age, greater stroke severity, hyperglycemia/diabetes, hypertension, atrial fibrillation, heart disease, and anticoagulant use.
- This pathology usually happens within 36 hours after thrombolytic infusion. Only about half of the patients with this condition are diagnosed 5–10 hours after the administration of tPA.
- The first step taken should be to immediately stop the infusion of tPA if it is still running. Computed tomography scan of the brain is the first imaging step in the evaluation of possible stroke or when there is suspicion of conversion to hemorrhagic after administration of thrombolytic agents.
- If hemorrhage is found (seen on computed tomography scan as the previous ischemic infarct with superimposed hyperintense cerebral hemorrhage), the next steps would be to collect baseline labs and reverse the anticoagulation using cryoprecipitate or other products. In addition, neurosurgery should be called for potential surgical treatment.
A 60-year-old male is being evaluated at the emergency department for a frontal right-sided headache. Skull X- rays show mild opacification of the right frontal sinus. Brain magnetic resonance imaging with and without contrast is performed. It shows an incidental 2.0 cm x 1.8 cm homogeneous enhancing mass at the atrium of the left lateral ventricle without evidence of ventricular trapping or edema on adjacent brain parenchyma. The mucosa of the frontal sinus is thickened and enhanced. On the physical exam, the patient is neurologically intact. He is prescribed nasal decongestants. What is the best next step in management for the incidental mass?
1. Follow-up brain magnetic resonance imaging with and without contrast in 6 months
2. Stereotactic needle biopsy
3. Left-sided craniotomy for tumor resection
4. Radio-oncologist consult for elective radiosurgery
1. Follow-up brain magnetic resonance imaging with and without contrast in 6 months
- A well-circumscribed, homogeneously enhancing mass in the atrium of the lateral ventricle is most likely an intraventricular meningioma.
- Intraventricular meningiomas are mainly benign, slow-growing lesions. However, it is essential to follow-up with serial imaging due to the risk of ventricular trapping and symptomatic parenchymal edema that may warrant surgical intervention.
- If there is documentation of tumor growth on follow-up magnetic resonance imaging and the diagnosis of meningioma by brain magnetic resonance imaging is clear. One may proceed with treatment with radiosurgery if the lesion is under 3.0 cm in all dimensions. If the diagnosis is unclear, then a less invasive stereotactic needle biopsy vs. open tumor resection is strongly suggested.
- Even if meningioma is found incidentally, when there is evidence of associated parenchymal edema or trapped lateral ventricle, then urgent/emergent surgery should be performed.
A 71-year-old male smoker with a past medical history of right lung adenocarcinoma presents with a small pupil on the right, drooping of the right eyelid, and decreased sweating on the right side of his face. Which of the following conditions would increase the size discrepancy between the pupils?
1. Examination in a brightly lit room
2. Examination in a dark room
3. Have the patient focus on a near object
4. Pharmacologically constrict the pupil prior to testing
2. Examination in a dark room
- This patient likely has Horner syndrome from disruption of the sympathetic chain along the apex of the lung due to his malignancy. Horner’s syndrome causes miosis, ptosis, and anhydrosis.
- The miotic pupil cannot dilate well. Therefore, examining the patient in a relatively dark room will increase the discrepancy in size between the pupils, since the other pupil will more effectively dilate.
- The patient should focus on a distant object to eliminate the near reflex. Pharmacologically constrict the pupil prior to testing would not be helpful.
- A bright room makes the evaluation of pupillary response to light difficult.
A 52-year-old female presented to the clinic with a 4-month history of pain and burning in the left hemithorax, initially treated as symptoms of herpes, without a satisfactory result, until it became more acute 13 days ago. Her past medical history is significant for type 2 diabetes mellitus for the past 4 years. She is taking metformin and sitagliptin for diabetes. Her BMI is 36 kg/m2. She underwent laparoscopic cholecystectomy 8 years ago. On physical exam, she has mild paraspinal tenderness, normal patellar reflexes, normal muscle strength in her lower extremities, and a normal gait exam. MRI thoracolumbar spine reveals thoracic disk herniation at T7-T8 interspace. Which of the following is the next best step in the management of this patient?
1. Thoracic laminectomy
2. Thoracic discectomy
3. Physical therapy and NSAIDs
4. Epidural steroids
2. Thoracic discectomy
- The clinical presentation and imaging studies are consistent with a thoracic disk herniation with spinal cord compression causing symptoms of thoracic myelopathy.
- Surgical intervention is considered the treatment of choice for symptomatic thoracic disc herniations.
- Surgery will allow for the removal of the ossified disc, decompressing the region, and relieving pressure on the nerve or spinal cord.
- The initial treatment of thoracic discogenic syndrome is usually conservative (nonoperational) since some disc herniations have been reported to stabilize/regress with time, especially in younger patients. However, this patient is displaying signs and symptoms of thoracic myelopathy, which warrants surgical management.
A 35-year-old man presents with a two-month history of a gradually enlarging, painful scrotal mass. He has a history of acromegaly, for which he underwent transsphenoidal surgery, thyroid nodules, and multiple lentigines. The patient was adopted and does not take any medications. Examination is notable for diffuse blue-black ovoid macules and a firm 4 cm scrotal mass. After further workup consistent with a Leydig cell tumor, the patient undergoes left radical orchiectomy and subsequently is found to have a cardiac myxoma. Given the likely diagnosis, which of the following manifestations of this patient’s condition is most associated with mortality?
1. Acromegaly
2. Cardiac disease
3. Skin malignancy
4. Testicular cancer
2. Cardiac disease
- Patients with Carney complex have mortality most associated with cardiac disease, specifically cardiac myxomas.
- Cardiac myxomas are associated with emboli and cardiac deficiency, for which even surgical excision can be insufficient as they can recur.
- Cardiac tumors can cause death in patients with Carney complex, either directly related to the tumors or surgical complications that occur during or after their removal.
- Other major causes of mortality include metastatic or intracranial psammomatous melanotic schwannoma, carcinoma or metastatic tumor, and non-cardiac postoperative complications
A 4-year-old boy is brought to the provider with an inability to carry out his daily activities. He has difficulty running, climbing stairs, and falls frequently. His maternal uncle, who died of respiratory failure, had similar problems and was wheelchair-bound by the age of 12 years. What is the diagnostic test for this patient?
1. Creatine kinase levels
2. Whole-body PET scan
3. Electromyography
4. Gene analysis
4. Gene analysis
- Duchenne muscular dystrophy (DMD) is a severe form of inherited muscular dystrophies. It is described as the most common hereditary neuromuscular disease that does not have a predilection for any race or ethnic group. Mutations in the dystrophin gene cause progressive muscle fiber degeneration and weakness.
- This type of dystrophy initially may present with difficult mobility but progresses to such an extent that patients are unable to carry out activities of daily living and must use wheelchairs. Cardiac and orthopedic complications are not uncommon, and death usually occurs in the twenties due to respiratory muscle weakness or cardiomyopathies.
- A dystrophinopathy should be considered in patients with symptoms of weakness, a characteristic physical exam, and a possible family history of the disease.
- Patients with DMD exhibit the complete or near-complete absence of the dystrophin gene. This is a diagnostic test of DMD. Dystrophin immunoblotting can be utilized to predict the severity of the disease.
A 62-year-old male has a one-week history of nausea, vomiting, and paresthesias of the right hand and foot. On the day of admission, he had a generalized seizure followed by a headache that increases when he bends forward. There is right facial droop and loss of double simultaneous tactile stimulation. MRI shows a left posterior frontal, intraparenchymal, non-enhancing mass with a local mass-effect on the lateral ventricle consistent with a brain tumor. Transformation of which brain cell type is most likely the etiology of the tumor in this patient?
1. Lymphocyte
2. Neuron
3. Star-shaped glial cells
4. Oligodendrocyte
3. Star-shaped glial cells
- The most common primary brain tumors in adults are in the family of astrocytomas. Within the astrocytomas. Glioblastoma Multiforme, WHO grade 4 is most common with a peak incidence in ages 60-70 with a male predominance.
- Astrocytoma originates in astrocytes, which are a kind of glial cells in the cerebrum which are star-shaped. It is the most common glioma, usually affecting the brain and sometimes the spinal cord. Amongst brain tumors, glial tumors comprise 60% of the tumors.
- Symptoms can be divided into two categories: general & focal. General symptoms include headache (usually early morning), nausea, vomiting, cognitive difficulties, personality changes, and gait disorders. Localizing symptoms include seizures, aphasia, or visual field defects. A visual field defect is commonly unnoticed by the patient, may be revealed after it leads to injury such as automobile accidents.
- The only test necessary to diagnose a brain tumor is neuroimaging. MRI is the best imaging for the same. Gadolinium contrast-enhanced MR imaging should be used whenever possible. If there is any contraindication for MRI, such as joint implants or pacemakers in situ, computed tomography or CT may be done. Lower-grade gliomas aren’t contrasting enhancing, so fluid-attenuated inversion recovery (FLAIR) sequences of MRI are done. If a tumor is found, a biopsy must be performed.
A 28-year-old man presents for preoperative evaluation before elective surgery for a distal ulnar fracture. He injured his arm during a basketball game and has been in a sling since the incident. He reports numbness and tingling. When recording somatosensory evoked potentials (SEPs) from the patient’s injured arm, which potential is most likely to show changes from baseline?
1. N9
2. N14
3. N20
4. N22
1. N9
- Somatosensory evoked potentials (SEP) monitoring is employed intraoperatively to identify, and ideally, avoid impending permanent damage to neurologic structures. SEP waveforms change in response to many different factors, some of which can cause permanent damage.
- The N9 potential is generated at Erb’s point and reflects the peripheral components of the monitored sensory pathway.
- The mechanism of the patient’s injury is most consistent with a peripheral nerve injury, which would affect the N9 potential.
- The N22 potential is generated at the gray matter of the spinal cord. It is unlikely this potential would be changed, given the patient’s reported mechanism of injury. The N20 potential is generated at the cortex and would not show abnormalities due to the patient’s fall. The N14 potential is generated at the cervicomedullary area.
A 34-year-old woman with a BMI of 42 kg/m2 presents to the clinic with complaints of numbness and paresthesias in the lateral aspect of the right thigh. The patient says she has tried gabapentin in the past with no relief in symptoms. She had an MRI of the lumbar spine, which was reported normal. What is the most appropriate placement of the peripheral stimulator lead in this patient?
1. Lateral femoral cutaneous nerve
2. L2 nerve root
3. Sciatic nerve
4. Femoral nerve
1. Lateral femoral cutaneous nerve
- The patient’s clinical symptoms are consistent with meralgia paresthetica or lateral femoral cutaneous nerve syndrome.
- This condition is most common in morbidly obese females due to chronic femoral cutaneous nerve compression with tight clothing.
- Peripheral nerve stimulation is an efficacious treatment option for this condition where the PNS leads are placed parallel to the lateral femoral cutaneous nerve.
- All the other nerves do not match the area of distribution of paresthesia.
A 50-year-old man presents to the clinic with left- sided facial pain for the past 6 months. He describes it as a sharp stabbing pain along the left forehead, and it appears in short episodes. During the episodes, he experiences lacrimation. He uses carbamazepine but is seeking a permanent solution. Radiofrequency thermocoagulation of the implicated ganglion is planned. What is the most appropriate anatomic location to mark the site for needle entry for this procedure in this patient?
1. Anterior to the mandible and inferior to the zygomatic arch
2. Medial to the occipital artery
3. Directly on the point of maximal tenderness
4. At the infraorbital foramen
1. Anterior to the mandible and inferior to the zygomatic arch
- This patient most likely has trigeminal neuralgia due to episodes of sharp unilateral pain in the V1 territory along with lacrimation.
- The infrazygomatic approach to sphenopalatine ganglion radiofrequency ablation involves entering the skin anterior to the mandible and inferior to the zygomatic arch.
- Sphenopalatine ganglion RFA is a relatively quick, cost- effective, and safe procedure with a low complication rate. It has demonstrated that it is a useful method to treat chronic cluster headaches.
- The location for an occipital nerve block is medial to the occipital artery. Injecting directly on the point of maximal tenderness is a technique for trigger point injections and would not be indicated for a patient experiencing trigeminal neuralgia. The infraorbital foramen is the location for an infraorbital nerve block. This would be effective for pain involving the lower eyelid, nares, and upper lip. It would not be effective for pain on the forehead due to trigeminal neuralgia.
A 35-year-old patient presents with acute onset worst headache of his life. CT head revealed an acute subarachnoid hemorrhage. CT cerebral angiography showed evidence of an ophthalmic artery aneurysm. The treating clinician planned for microsurgical clipping of the aneurysm. He however wants to safeguard from the possible intraoperative rupture of the lesion. Which of the following is the most rational approach to control hemorrhage following the same in the patient?
1. Proximal temporary clip application
2. Suture control of the proximal internal carotid artery
3. Adenosine induced cardiac arrest
4. Neck control of the internal carotid artery
4. Neck control of the internal carotid artery
- Inadvertent rupture of the ophthalmic artery aneurysm is a devastating complication with great difficulty in controlling the resulting hemorrhage.
- Preoperative neck control of the internal carotid artery is the most rational approach to control such adverse intraoperative events.
- This effectively minimizes the blood inflow in the internal carotid thereby allowing a surgical environment in the correct and safe application of the permanent clipping.
- An adenosine-induced cardiac arrest requires expert neuro anesthesia support. Application of the proximal temporary clip is not feasible in the case of an ophthalmic segment of the internal carotid artery.
A 17-year-old male patient with severe neurological injury after a motor vehicle collision requires prolonged mechanical ventilation. He has been intubated for 14 days and remains at a Glasgow coma scale of 6 since his decompressive craniotomy two weeks ago. He has a nasogastric tube in place and has been on stable ventilator settings for the past 48 hours but has failed ventilator weaning multiple times. He initially developed post- traumatic diabetes insipidus after his accident, but his fluid balance has been stable for five days. He is being prepared to be transferred to a neurological care center, which requires a tracheostomy before transportation there. What is the next best step in management?
1. Percutaneous gastrostomy to prevent tracheoesophageal fistula
2. Electroencephalogram to determine higher brain function to aid in prognosis discussion
3. Discussion regarding goals of care with the family and caregivers
4. Placement of a low-pressure cuffed tracheostomy tube to minimize the risk of subglottic or tracheal stenosis
3. Discussion regarding goals of care with the family and caregivers
- This patient has suffered a devastating neurological injury, as evidenced by his Glasgow coma score of 6. This portends a dismal prognosis as it has been unchanged for 14 days.
- It is important to ascertain the patient’s and the family’s wishes and goals of care before embarking upon additional procedures in tragic situations such as this, and palliative and hospice options must be discussed.
- The respiratory drive is in the reptilian brain and may persist even if higher cortical functions have been lost. This can help families interpret what their loved ones would have wanted in such a situation.
- Electroencephalogram (EEG) can be used to assess higher cortical electrical activity and may aid in such discussions. This is required in some U.S. states but can provide another prognostic indicator to provide to families regarding the potential recovery.
A 24-year-old woman falls approximately 15 feet from a ladder while cleaning her gutters. At the scene, she is non- responsive and intubated. She is taken to the local hospital, where imaging shows diffuse axonal injury with numerous microhemorrhages and shear injury. The patient is given multiple medications to manage presumed intracranial hypertension from cerebral edema, and an intracranial pressure monitor is placed. Her intracranial pressure is initially controlled with medical interventions, including intravenous mannitol, but at 36 hours post-injury, her intracranial pressure begins to rise and worsens despite medical intervention. What is the mechanism most likely responsible for her increased intracranial pressure?
1. Dehydration
2. Medication extravasation
3. Pyretic effects of medications
4. Upregulated metabolism of medications
2. Medication extravasation
- Mannitol is an osmotic diuretic used to treat intracranial hypertension and cerebral edema.
- With frequently repeated doses of mannitol, the mannitol can begin to leach/extravasate across a leaky blood-brain barrier and effectively draw water into the brain, causing worsening cerebral edema.
- Doses of mannitol range from 0.25 g/kg to 2 g/kg given over 30- 60 minutes, with effects lasting approximately 6 hours.
- Mannitol is contraindicated in patients with severe renal disease, severe pulmonary disease, dehydration, progressive heart failure, or electrolyte abnormalities.
A 28-year-old male is shifted to the intensive care unit due to an altered sensorium associated with a high-grade fever. He was diagnosed with acute myeloid leukemia and had undergone 2 cycles of induction chemotherapy with the completion of the last cycle 10 days ago. On the examination, there is erythema and black eschar surrounding the left eye. The left pupil was fixed & dilated. CT revealed enhancing mass in the ethmoidal sinus as well. The periodic acid-Schiff stain of the material obtained following the surgical debridement demonstrated broad hyphae with right-angle branching. What is the best next step in the management of the patent?
1. Amphotericin B
2. Fluconazole
3. Antitubercular therapy
4. Chloroquine
1. Amphotericin B
- The clinical signs and symptoms in the patent are highly suggestive of a rhino-orbital mucormycosis.
- The periodic acid-Schiff stain demonstrating broad hyphae with right-angle branching is the hallmark of the disease process.
- Parenteral Amphotericin B is advocated for the management of rhino-orbital mucormycosis.
- Liposomal amphotericin has better tissue penetration and minimal renal toxicities, however, the cost is a major limiting factor.
A 6-year-old boy is diagnosed with a posterior fossa cystic tumor and is awaiting surgery. The neurosurgeon informs the patient’s parents that he could develop acute hydrocephalus if there is bleeding into the tumor. Which of the following would be the last sign to manifest if the patient develops this complication?
1. Headache
2. Symptomatic papilledema
3. Abducens nerve palsy
4. Ataxia
2. Symptomatic papilledema
- Critically increased intracranial pressure initially will cause decreased consciousness.
- Other signs and symptoms are likely to occur in the following sequence: headache, nausea, vomiting, irritability, and abducens nerve palsy.
- Papilledema is not present in all patients with increased intracranial pressure.
- Symptomatic papilledema with vision loss only occurs with chronic or advanced increased intracranial pressure after the initial sequelae of
A previously healthy 38-year-old male accountant presents to the clinic complaining of lower back pain. The onset of pain was insidious, but the pain intensity has started to affect his work. He recently returned to his hobby, which is weight lifting after 4 months of brake he had to take to recover from his pulled hamstring. The neurological examination is normal. He has slightly limited back extension and is complaining of increased back pain during the both legs extension test while prone. What is the best initial step in the management of this patient?
1. Urgent MRI
2. Local anesthetic and corticosteroid injection
3. Recommend increasing the number of weights he’s been lifting
4. Simple analgesia and targeted physiotherapy
4. Simple analgesia and targeted physiotherapy
- This patient is most likely suffering from mechanical lower back pain secondary to the lumbar muscles deconditioning during his recent injury. Targeted physiotherapy to improve core and lumbar musculature strength is recommended before he returns to weight lifting training.
- Muscles most commonly affected in the pathology of the lower back pain are multifidus, erector spine core, and pelvic floor muscles.
- Increased back pain on passive leg extension and gently traction with patient prone is the most sensitive test to detect lumbar spine micro-instability secondary to core and lumbar spine musculature’s weakness/deconditioning.
- Increasing weight lifting regime prior to the core and lumbar spine musculature strengthening may lead to further deterioration of symptoms by altered muscle patterning and lack of the full stability of the spinal column.
A 71-year-old woman with a past medical history significant for hypertension, osteoarthritis of the spine, hyperlipidemia, opioid use disorder, and mechanical aortic valve on life prolonged anticoagulation presents to the office for a consultation for spinal cord stimulator implantation. The patient has a history of multiple back surgeries. She complains of low back pain that is burning in nature, persistent, moderate to severe, depending on the time of day. She denies numbness and tingling into her lower extremities. She states that her back pain is causing a significant impact on her quality of life. Her physical exam is unremarkable for any red flags; muscle strength, sensation, and deep tendon reflexes are within normal limits. For which of the following postoperative complications does the patient have the highest risk?
1. Spinal epidural abscess
2. Spinal epidural hematoma
3. Dural puncture
4. Spinal cord injury
2. Spinal epidural hematoma
- Spinal epidural hematoma is a medical emergency requiring urgent neurosurgical intervention; the patient’s lifelong anticoagulation puts her at increased risk.
- If it occurs, the hematoma must be decompressed urgently by neurosurgery.
- Spinal epidural hematomas and spinal cord trauma are extremely rare following stimulator implantation.
- Anticoagulation remains a relative contraindication to surgery. Given the patient’s history of valve replacement, a cardiologist should be consulted for the proper duration of stopping anticoagulation prior to surgery to limit the risk of a spinal epidural hematoma.
A 26-year-old female presents to the clinic for evaluation of amenorrhea. She denies being sexually active. She has missed her past four menstrual cycles. Her menarche was at 13, and the periods have been consistently 27-28 days apart. She complains of new headaches. Physical examination is unremarkable, and the patient is found to be of normal weight. Laboratory test reveals negative bHCG with a normal thyroid-stimulating hormone and prolactin level. MRI head showed a 2 cm sellar mass. The patient undergoes transsphenoidal surgery. The histological examination of the specimen shows sheets of differentiated non- keratinizing squamous epithelium with clear cystic fluid and crude papillae around fibrovascular cores. What is the likely mutation associated with this lesion?
1. BRAF
2. MEN
3. RET
4. CTNNB1
1. BRAF
- Craniopharyngioma is a neoplasm of Rathke pouch. These two theories correlate with the two histologic subtypes of craniopharyngiomas - adamantinomatous craniopharyngioma and papillary craniopharyngioma.
- Papillary craniopharyngiomas are primarily seen in adults. Somatic mutation in BRAF has been associated with papillary craniopharyngioma. Craniopharyngiomas have benign histology but malignant behavior.
- Somatic mutation in the CTNNB1 is proposed to be responsible for adamantinomatous craniopharyngioma development, which is commonly seen in children.
- MEN and RET mutations predispose to multiple endocrine neoplasias which include parathyroid, pituitary, thyroid, and gastrointestinal tumors.
A 10-year-old male was brought in by his mother. The mother states that she has noticed recent changes in the behavior of her son. His school grades are dropping, and he has been complaining of tiredness over the past few weeks. Recently he started wetting the bed at night and experiences increased thirst and urination. Complete physical examination is unremarkable. Significant laboratory findings include fasting blood glucose 75 mg/dl, serum sodium 149 mEq/L, plasma osmolality 297 mOsm/liter, urine osmolality 280 mOsm/liter, serum thyroid stimulating hormone (TSH) 0.3 mIU/L, and free T4 0.2 ng/dL. Urine osmolality did not increase after the water deprivation test. Plasma osmolality after desmopressin administration is 285 mOsm/L. Magnetic resonance imaging showed a small, homogenous mass in the suprasellar region of the brain. Tumor oncoproteins were not elevated. He subsequently underwent an endoscopic biopsy of the mass. A dual population of cells comprising of large polygonal cells with vesicular nuclei, prominent nucleoli, and distinct cell borders intermixed with small cells with coarse, dense nuclei and scant cytoplasm was detected on histological examination. Malignant cells were also detected in cerebrospinal fluid (CSF) cytology. What is the most effective treatment modality for this patient?
1. Complete craniospinal irradiation
2. Ventricular radiotherapy only
3. Chemotherapy followed by stem cell or bone marrow transplant
4. Chemotherapy only
1. Complete craniospinal irradiation
- Diabetes insipidus is the most common presentation of germinoma involving the suprasellar region. The patient develops enuresis, polyuria, and polydipsia. Serum osmolality is greater than urine osmolality on laboratory evaluation. Desmopressin administration normalized the serum osmolality.
- Abnormalities in the hypothalamic-pituitary axis cause panhypopituitarism and endocrinal insufficiency. This patient had hypothyroidism demonstrated by decreased serum TSH and free T4 levels.
- Timely diagnosis and treatment are critical for better survival. Tumor staging with imaging and CSF cytology helps to guide the appropriate therapy. Whole ventricular radiation is used in cases of localized pure seminoma.
- In patients with positive CSF cytology, more disseminated disease is suspected. Therefore, treatment is more aggressive with craniospinal irradiation for an effective outcome.
A 59-year-old woman presents to the clinic with concerns about hand and foot swelling and coarsening facial features. On clinical examination, she is noted to have a prominent supraorbital ridge, broad nose, acne, large lips, overbite, prognathism, tongue enlargement, and coarsening of facial features. Her fasting blood glucose level is 140 mg/dL. An IGF-1 level is obtained, which is high at 504 ng/mL (reference range: 117-321 ng/mL). She is being planned for medical treatment as she is surgically not fit. She has been prescribed a second-generation somatostatin analog. Two weeks later, she presented to the clinic with a fasting blood glucose of 200 mg/dL. Which of the following best describes the mechanism responsible for this patient’s increased blood glucose?
1. Binding to somatostatin receptor 3 (SSTR3), leading to the suppression of insulin secretion
2. Binding to somatostatin receptor 5 (SSTR5), leading to an increase in glucagon secretion
3. Binding to somatostatin receptor 5 (SSTR5), leading to the suppression of insulin secretion
4. Binding to somatostatin receptor 3 (SSTR3), leading to an increase in glucagon secretion
3. Binding to somatostatin receptor 5 (SSTR5), leading to the suppression of insulin secretion
- The patient in the clinical vignette most likely has acromegaly.
- Pasireotide is a second-generation somatostatin analog used in the treatment of acromegaly.
- Pasireotide preferentially binds to somatostatin receptor 5 and causes a suppression of insulin secretion.
- Pasireotide has little impact on glucagon secretion.
A 30-year-old female presents with complaints of amenorrhea and white nipple discharge for the past three months. She also complains of headaches and visual changes. She has no past medical history and currently takes no medications. Her vital signs show an oxygen saturation of 98% on room air, respiratory rate of 14 breaths per minute, heart rate of 82 beats per minute, blood pressure 130/75 mmHg, and temperature of 98.6 F (37 C). Physical examination reveals bitemporal hemianopsia. Neuroimaging reveals a 1.8 cm pituitary mass abutting the optic chiasm. Which of the following is an appropriate treatment strategy?
1. Treatment with an oral dopaminergic agonist
2. Treatment with an oral dopaminergic antagonist
3. Transcranial resection of the tumor
4. Transsphenoidal resection of the tumor
1. Treatment with an oral dopaminergic agonist
- The most likely diagnosis is a prolactinoma. Prolactinomas clinically present because of the mass effect (visual changes) of the tumor or because of hyperprolactinemia (amenorrhea, loss of libido).
- Microprolactinomas (less than 1 cm) can present with symptoms of hyperprolactinemia or are detected incidentally on neuroimaging done for other reasons. Macroprolactinomas, on the other hand, often present with mass effects on the surrounding structures.
- The preferred treatment for prolactinomas is medical therapy. Cabergoline and bromocriptine are two commonly used dopamine agonists.
- Transsphenoidal surgery is preferred and is indicated for unsuccessful medical therapy to lower prolactin levels and decrease tumor size after several months of maximum dose medical treatment. It can also be considered in a female with a large prolactinoma (more than 3 cm) who wishes to become pregnant.
A 55-year-old female with a past medical history of hypertension and hyperlipidemia presents to the emergency department with a severe headache, which began an hour ago. The patient denies any head trauma. The patient denies headache like this in the past. On physical examination, blood pressure is 180/100 mm Hg, respiratory rate is 20/minute, pulse rate 100/minute, and oxygen saturation is 99% on ambient air. The patient is stuporous, and the neurological exam reveals mild hemiparesis. CT brain without contrast shows subarachnoid hemorrhage (SAH). What is this patient’s mortality risk?
1. 20%
2. 40%
3. 60%
4. 80%
4. 80%
- According to the Hunt and Hess classification system for the severity of symptoms, this patient is in grade 4, stuporous with moderate to severe hemiparesis. Her mortality risk, according to this classification system, is 80%.
- The Hunt and Hess classification system is used to classify the severity of SAH based on clinical findings and to predict outcome and mortality. There are 5 different grades ranging in the severity of symptoms, which correlate with the overall mortality of SAH. Grade 1: mild headache with slight nuchal rigidity with approximately 30% mortality. Grade 2: severe headache with full nuchal rigidity and no neurologic deficits other than a cranial nerve palsy with approximately 40% mortality. Grade 3: drowsiness or confusion with a mild focal deficit with approximately 50% mortality. Grade 4: stuporous with moderate to severe hemiparesis with approximately 80% mortality. Grade 5: coma with decerebrate posturing with approximately 90% mortality.
- The modified Fisher classification describes the amount of blood seen on a head non-contrast computed tomography (CT) scan to predict the likelihood of developing vasospasm: Fisher 0: no blood detected. The incidence of symptomatic vasospasm: 0%. Fisher 1: thin focal or diffuse SAH. The incidence of symptomatic vasospasm: 18%. Fisher 2: thin focal or diffuse SAH with intraventricular hemorrhage. The incidence of symptomatic vasospasm: 35%. Fisher 3: thick focal or diffuse SAH with no intraventricular hemorrhage. The incidence of symptomatic vasospasm: 31%. Fisher 4: thick focal or diffuse SAH with intraventricular hemorrhage. The incidence of symptomatic vasospasm: 68%.
- Oral nimodipine should be started to improve the outcome in patients with ruptured cerebral aneurysms.
A 46-year-old female presented with defective vision in the right eye since the age of 13 years. She has a history of fever and generalized rash over the body at the same time. Anterior segment examination reveals grade 2 nuclear sclerosis in the right eye. Fundus examination reveals mild temporal pallor. Visual acuity is 20/240, improving to 20/40 with -3D spherical correction. Color vision and central fields reveal no defect. Intraocular pressure is within normal limits. What will be the next best step in management?
1. Best corrected glasses
2. Phacoemulsification with foldable IOL in the right eye
3. CT scan of the brain
4. Humphrey filed analysis
4. Humphrey filed analysis
- The clinical scenario is suggestive of a patient having a cataract with temporal disc pallor. There is a history of fever and rash at a young age which is probably the reason for disc pallor. In this scenario, it is important to rule out any brain pathology before any intervention can be done. In this scenario, it is important to do a Humphrey field analysis followed by a CT scan to rule out any field defect and brain pathology. Hence, it is important to do an HFA in this case.
- There is a possibility of amblyopia in this case.
- Hence surgical intervention should be done under a guarded visual prognosis.
- CT scan is mandatory to rule out any intracranial pathology and space-occupying lesion.
A 70-year-old man presents with chronic neck pain that radiates into his right arm. These symptoms have been ongoing for the past eight weeks. Examination reveals diminished right brachioradialis reflex, diminished sensation on the right thumb, and right wrist extension weakness. The Spurling test is positive on the right. Hoffman sign is negative bilaterally. The patient has been taking NSAIDs for the past four weeks and attending physical therapy for the past six weeks without any relief of his symptoms. Which of the following is the most appropriate next step in the management for this patient?
1. Refer to neurosurgery
2. Continue current treatment course
3. Obtain an MRI of the cervical spine
4. Refer for a cervical epidural steroid injection
3. Obtain an MRI of the cervical spine
- The next best step for this patient is to obtain an MRI of the cervical spine to evaluate for a disc herniation and/or degenerative changes that may be causing neural foraminal stenosis.
- Based on the exam findings, there is likely a right C6 nerve root compression that is causing the patient’s symptoms. C5-C6 and C6-C are the most common levels of disc degeneration.
- Referral to a pain specialist or physiatrist for an epidural steroid injection is appropriate after the failure of conservative measures. However, referring healthcare providers should obtain an MRI first to confirm the diagnosis of a compressed nerve root or spinal cord.
- Referral for operative treatment is not indicated unless all non- operative measures have been exhausted without improvement and/or the patient is experiencing progressive or severe cervical myelopathy.
A 39-year-old man suffers a fall from a horse and hits the occipital area on the ground. He lost consciousness momentarily and had one episode of vomiting. He is brought to the emergency department for evaluation. On arrival, he has a Glasgow coma scale of (GCS) 13/15 but follows instructions. An emergency CT head shows a 3 cm frontal contusion. He is admitted to the intensive care unit for observation. On the second day, he has a GCS of 15/15 and is sent to the ward. On the third day of admission, he becomes disoriented and minimally responsive. Repeat CT head shows the progression of the traumatic contusion. Which of the following is the most significant parameter governing the progression of the lesion observed in the patient?
1. The initial volume of the hemorrhage
2. Platelet count
3. Admission Glasgow coma scale
4. Location of hemorrhage
1. The initial volume of the hemorrhage
- Hemorrhagic progression of traumatic cerebral contusion is observed in almost 75% of cases.
- Multivariate analysis has shown that the initial volume of the hemorrhage is the most important parameter governing the risk of progression of the contusion.
- It accounts for almost 30% predictability of the risk of hemorrhagic progression of the contusion in the follow-up imaging.
- This parameter therefore can be a reliable clinical marker in prognosticating clinical outcomes among patients with traumatic brain contusions.
A 2-year-old female child presents to the clinic with her mother, with chief complaints of poor feeding, vomiting, and incessant crying over the last few days. The birth, immunization, and developmental histories are unremarkable. There is no significant medical history in any of the family members. The examination reveals an irritable child who tends to hit her head with her fists. On examination, there is a single bruise over the head and one on the chest. The head circumference is 54 cm. The temperature is 38.28 C (100.9 F). On ocular examination, the retina cannot be visualized. The rest of the exam is normal. A CT scan reveals diffuse hyperintensities in both the lateral ventricles. What is the most likely diagnosis?
1. Meningitis
2. Arteriovenous malformation rupture
3. Subdural hemorrhage
4. Tuberculous meningitis
3. Subdural hemorrhage
- This patient with poor feeding, incessant crying, vomiting, vitreous hemorrhage, and CT scan showing hyperintensities in the lateral ventricles is most likely a case of ‘Shaken baby syndrome.’ This is an example of countercoup brain injury. The injury occurs when the abuser shakes the baby violently, causing acceleration-deceleration related shearing forces that damage both the axons and cerebral vessels. The bruise on the head could suggest injury of the child against a hard object leading to deceleration injury.
- Shaken baby syndrome often presents with subdural hemorrhage and retinal hemorrhage signs. However, it can also sometimes lead to vitreous hemorrhage that makes it difficult to appreciate the retinal hemorrhage.
- Traumatic brain injury patients require a thorough general trauma evaluation. These patients need a detailed neurological examination and require a head CT for the initial assessment of brain injury.
- Meningitis will also reveal signs of meningeal irritation absent in this patient. Photophobia and not vitreous hemorrhage is the expected ocular finding. Arteriovenous malformation rupture can also present with symptoms of raised headache, poor feeds, and vomiting. However, an ocular exam will not reveal a vitreous hemorrhage. Tuberculous meningitis will not present with symptoms of raised intracranial pressure acutely and will have a longer symptomatic phase.
A 3-year-old boy is being evaluated for a triangular shape of the anterior head. He has a preferred sleeping position. His forehead has a prominent midline forehead ridge. Computed tomography of the head shows that the frontal bone has a triangular shape with a closed metopic suture. There is anterior displacement of the coronal sutures, widening of the posterior parietal regions, pterional constriction, and flattening of the supraorbital ridges with lateral orbital hypoplasia. Hypotelorism is also present. All the other sutures are patent. During which of the following time periods did the involved suture most likely close in this patient?
1. Before 3 months
2. Between 6 months and 12 months
3. Between 12 months and 24 months
4. After 24 months
1. Before 3 months
- Metopic suture closure starts at 3-4 months of age and is complete at 8-9 months in most individuals. Premature closure before the third month will cause trigonocephaly.
- The metopic suture closure starts at the nasion, proceeding superiorly, and terminates at the anterior fontanelle. Approximately 5.1% have the suture open after one year of age. By two years of age, it should have closed.
- The metopic suture’s physiologic fusion occurs between 3 and 19 months.
- A head computed tomographic scan with 3D reconstruction is performed to confirm the diagnosis and plan the surgery. It will show that frontal bones have a triangular shape, hypotelorism, anterior displacement of the coronal sutures, widening of the posterior parietal regions, pterional constriction, and flattening of the supraorbital ridges with lateral orbital hypoplasia.
A 67-year-old man with a past medical history of hypertension, alcohol use disorder, depression, gout, and benign prostatic hyperplasia is admitted to the intensive care unit with a grade 3 subarachnoid hemorrhage (modified Fischer scale). A cerebral aneurysm is identified on angiography, and endovascular coiling is done to reduce the risk of further bleeding. Seven days post-procedure, the patient reports nausea and headache. There is no dizziness on standing, capillary refill time is normal, and vitals show no new increase in the heart rate or fall in the blood pressure. A current set of labs is shown below. CT brain is negative for further findings. What is the best next step in treatment?
1. 3% sodium chloride solution
2. 0.9% sodium chloride solution
3. 0.9% sodium chloride with 5% dextrose solution
4. Total fluid restriction
1. 3% sodium chloride solution
- This scenario describes symptomatic hyponatremia following subarachnoid hemorrhage (SAH) due to increased anti-diuretic hormone (ADH) secretion.
- Hyponatremia following SAH is either due to increased secretion of ADH (majority) or cerebral salt wasting. If the hyponatremia is due to increased ADH, the patient is euvolemic. If the hyponatremia is due to cerebral salt wasting, there is clear evidence of hypovolemia.
- Hyponatremia, here, is best treated with hypertonic saline (3% sodium chloride).
- Some clinicians prefer normal isotonic saline (0.9% sodium chloride) if they feel hyponatremia is due to cerebral salt wasting alone. Notably, normal saline is avoided in patients with SIADH as it further drops the sodium level. Fluid restriction leads to hypovolemia, which aggravates the risk of cerebral vasospasm. Thereby, the total fluid restriction should be avoided in these people
A 65-year-old female with a past medical history significant for osteoporosis and type two diabetes presents to a clinic with back pain. She states that she slipped and fell on her back yesterday while working in the kitchen. She noticed a sharp electrical pain and was unable to get up for 15 minutes. Today, she is ambulating without gait instability but says the pain is not going away with her usual dose of ibuprofen. She denies saddle anesthesia, urinary, and fecal incontinence. On physical examination, she has midline and low back tenderness but no lower extremity weakness. Which of the following is the most rational initial imaging modality to be advised in the patient?
1. X-ray lumbar spine
2. CT Lumbar spine
3. MRI lumbar spine
4. Ultrasound of the lower back
1. X-ray lumbar spine
- The X-ray spine is the most rational imaging modality to be advised in an out-patient set up in a patient presenting with localized back pain and no neurological deficits following a fall incident.
- X-ray is a readily available, cheap, and reliable imaging modality in evaluating and initial screening patients with a traumatic spinal injury.
- It has high efficacy in outlining traumatic osseous spinal injuries such as fractures and subluxation.
- It is a reliable tool in safely dichotomizing patients who need further imaging assessments with the help of CT and MRI imaging.
A 35-year-old man presents for continuous ringing in his right ear for the past few weeks. He also reports a constant decrease in hearing on the affected side and occasional headaches that have been worsening over the past few weeks. The physical examination is normal. His audiogram reveals sensorineural hearing loss in his right ear. MRI brain demonstrates a 2 cm lesion at the cerebellopontine angle that enhances with gadolinium and does not appear to have a “tail.” What is the most likely cause of this patient’s presentation?
1. Neoplasm of cranial nerve VIII
2. Vascular malformation
3. Endolymphatic hydrops
4. Meningioma
1. Neoplasm of cranial nerve VIII
- This patient presents with continuous, unilateral tinnitus and hearing loss. Sensorineural hearing loss along with a cerebellopontine angle (CPA) mass on MRI is consistent with the diagnosis of acoustic neuroma.
- Tinnitus should be considered a clinical presentation rather than a disease. A neoplastic proliferation of the vestibulocochlear nerve (cranial nerve VIII) can give rise to tinnitus and concomitant hearing loss and vertigo.
- Patients usually present with gradually progressive hearing loss and tinnitus. MRI brain is usually the modality of choice and will demonstrate a CPA tumor. Meningioma often demonstrates a “tail” of enhancement, denoting its origin from the meninges rather than from nervous structures.
- Careful history with a description of tinnitus along with examination is the key to making an accurate diagnosis. Vascular causes of tinnitus are usually pulsatile in nature, while Meniere causes episodic tinnitus with hearing loss and vertigo and will not demonstrate a mass at the CPA.
What is the most common reason that adults develop spondylolisthesis?
1. Malignancy
2. Trauma
3. Degenerative
4. Arthritis
3. Degenerative
- Spondylolisthesis can be congenital or develop during adulthood.
- The disorder may result from physical stress to the lower spine from sports, carrying heavy items, trauma, and general wear and tear.
- In most cases, it is the degenerative changes in the spinal components that lead to spondylolisthesis.
- The condition carries a high morbidity and leads to prolonged disability
A 49-year-old male patient presents to the hospital for evaluation of hearing difficulty. The patient reports progressively increasing difficulty with hearing. He also complains of an occasional ringing sound in his left ear. Audiometric examination reveals an asymmetric sensorineural hearing loss in the left ear of mild severity. Non-contrast CT scan reveals a mass in the left cerebellopontine angle that is isodense. MRI reveals an avidly enhancing mass following contrast injection. The mass is seen eroding into the left internal auditory canal. A preliminary diagnosis of vestibular schwannoma is made. The patient wants to know the prognosis and available treatment options for his tumor. He makes it very clear that he wants a definitive solution that has minimum effect on his functionality. What is the most suitable option for this patient?
1. Surgery via retrosigmoid approach
2. Radiation therapy
3. Surgery via middle fossa approach
4. Surgery via translabyrinthine approach
1. Surgery via retrosigmoid approach
- The retrosigmoid approach is the most commonly used approach for the resection of cerebellopontine tumors.
- Surgery provides a definitive cure and the choice of surgical approach is influenced by the size of the tumor, the extent of the tumor, and baseline hearing status.
- The retrosigmoid approach provides maximal exposure for the resection of the tumor. A combined microscopic/endoscopic approach can help access the intracanalicular portion of the tumor.
- Middle fossa and retrosigmoid approaches help to preserve hearing function, but the risk of facial nerve injury is slightly higher with the former.
A 35-year-old man with a history of chronic lower back pain presents to the clinic for further evaluation and treatment. The patient reports living an active lifestyle, playing football and soccer with his friends frequently. He also reports having some mild trauma to his back while playing but never had to see a clinician. On physical examination, there are scars on the right lower back. On palpation, the right lumbar muscles are tense and hypertrophic. On the range of motion testing, he is unable to bend laterally to his left side fully and that he feels the most amount of pain towards the end of the movement. According to the McKenzie classification, the patient’s condition is most appropriate to be classified as which of the following?
1. Postural syndrome
2. Derangement syndrome
3. Dysfunction syndrome
4. Sacroiliac joint disorder
3. Dysfunction syndrome
- The dysfunction syndrome is pain, which is caused by the mechanical deformation of structurally impaired soft tissue; this may be due to traumatic, inflammatory, or degenerative processes, causing tissue contraction, scarring, adhesion, or adaptive shortening.
- The hallmark is a loss of movement and pain at the end range of motion. In this patient, he has limited side bending to the left, with most of the pain felt at the end, suggesting a dysfunction syndrome.
- Successful treatment focuses on patient education and the mobilization of movement in the direction of the patient’s dysfunction/pain. The goal is to focus on tissue remodeling, which can be a prolonged process.
- Sacroiliac joint disorders would fall under other or nonmechanical syndrome under the Mckenzie classification.
