Section 3 Flashcards

1
Q

A 66-year-old female was admitted to the ICU after a motor vehicle accident causing a severe head injury. Brain death diagnosis was uncertain by physical examination, and the apnea test could not be performed due to CO2 retention. A transcranial Doppler (TCD) ultrasound on the middle cerebral arteries bilaterally did not detect any flow tracing. Which of the following is the next best step in managing this patient?
1. Declare brain death
2. Order somatosensory evoked potentials
3. Repeat TCD after one day
4. Continue medical management

A

2. Order somatosensory evoked potentials

  • TCD can confirm brain death if it shows absent diastolic pulsations or small peaked systolic pulsations. The absence of flow tracing is inconclusive of brain death, as it may be due to an unsuitable window.
  • Somatosensory evoked potentials may be ordered to determine brain death as TCD is inconclusive for this patient.
  • The absence of flow tracing by TCD does not confirm brain death, as it may be due to an unsuitable window. Another ancillary test should be performed.
  • Normal PCO2 is a prerequisite to performing the apnea test.
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2
Q

A 67-year-old female presents with a 1-hour history of right-sided weakness and aphasia. She has a history of atrial fibrillation and is taking aspirin only. The patient is alert and able to follow one-step commands. There is impairment of rightward gaze and left gaze deviation. Right face and arm flaccid paresis are present, but she can lift her right leg. There are decreased reflexes on the right side. What is the most commonly used study in a patient with this presentation?
1. Brain MRI
2. Brain CT
3. CT angiography
4. CT perfusion scanning

A

2. Brain CT

  • The patient has had an acute cerebrovascular accident and is a candidate for tissue plasminogen activator (tPA).
  • A noncontrast brain CT is the most commonly used study in the acute evaluation of patients with a suspected acute stroke.
  • CT scanning is more commonly available, less expensive, and provides faster image acquisition than MRI. CT also can be used in patients who are unable to tolerate or who have contraindications to MRI.
  • CT angiography, CT perfusion scanning, and MRI also can be used for emergent evaluation.
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3
Q

A SCUBA diver presents to the urgent care center with complaints of double vision after diving. This is his first dive since being newly certified four months ago. Upon visual examination, some bruising and swelling around his lower forehead and some eye redness is noted. He is also seen to have trouble moving one of his eyes laterally while complaining of diplopia. Which of the following is the next best step in the management of this patient?
1. Place the patient on oxygen and transfer to a facility with a decompression chamber
2. Reassure the patient that this is a mild injury and should resolve in a few weeks
3. Order an MRI or CT to evaluate the orbits of the eye
4. Discharge from the emergency department and refer to an ophthalmologist for a dilated fundoscopic examination

A

3. Order an MRI or CT to evaluate the orbits of the eye

  • The patient’s symptoms and exam are concerning for a subperiosteal hematoma involving the orbit. Imaging is indicated to confirm this diagnosis. MRI has the highest sensitivity, but CT may be initially used if MRI not available.
  • The examiner must be able to distinguish signs of a more severe injury. The warning signs would include severe eye pain, diplopia, or loss of visual acuity.
  • Oxygen should only be administered to patients with a suspected decompression injury. A mask squeeze is considered a traumatic injury as the result of “suction” of such force to disrupt cell membranes and rupture small vessels.
  • This patient will need evaluation by an ophthalmologist and possibly a fundoscopic examination. However, this condition is likely an emergency and may require surgical intervention or drainage.
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4
Q

Which of the pathophysiological mechanisms of Dejerine-Roussy syndrome is also proposed to be seen in other neurological processing such as memory?
1. Central disinhibition
2. Central sensitization
3. Central imbalance
4. The grill illusion theory

A

2. Central sensitization

  • Dejerine-Roussy syndrome is a type of central post-stroke pain syndrome caused by damage to the thalamus.
  • The synaptic efficacy is increased due to repetitive stimulation and will cause a response to be evoked at suboptimal levels of stimuli. This mechanism also is seen in the generation of memory.
  • Central imbalance is the cause of a spectrum of pain quality perceived by patients with Dejeine-Roussy syndrome.
  • The grill illusion theory of pathophysiology is not seen in the generation of memory.
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5
Q

What occurs with the induction of anesthesia using only nitrous oxide?
1. Increased intracranial pressure
2. Decreased cerebral blood flow
3. Decreased intracranial pressure
4. Cerebrovascular dilatation

A

1. Increased intracranial pressure

  • Induction with nitrous oxide is associated with elevated cerebral blood flow and increased intracranial pressure.
  • Nitrous oxide induces intoxication, euphoria, dysphoria, spatial disorientation, temporal disorientation, and reduced pain sensitivity. Some users will have uncontrolled vocalizations and muscle spasms.
  • If pure nitrous oxide is inhaled without oxygen, this can cause oxygen deprivation resulting in hypotension, syncope, and myocardial infarction.
  • Long-term exposure may cause vitamin B12 deficiency. Symptoms of vitamin B12 deficiency include sensory neuropathy, myelopathy, and encephalopathy. Symptoms are treated with high doses of vitamin B12, but recovery can be incomplete.
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6
Q

A 65-year-old male patient was brought to the emergency department following the sudden onset of headache and right sided weakness. On examination, he also has ptosis of his left eye with his eye laterally deviated. An urgent MRI brain, including diffusion-weighted images (DWI) and apparent diffusion coefficient (ADC), is planned. Based on this clinical scenario, the site of stroke is best located at which of the following territory?
1. Oculomotor nucleus region
2. Rostral oculomotor fascicular region
3. Caudal oculomotor fascicular region
4. Cavernous sinus

A

3. Caudal oculomotor fascicular region

  • The patient has involvement of the corticospinal tract, medial rectus, and the levator palpebrae superioris.
  • The fascicular arrangement of the midbrain oculomotor nerve is speculated to be a pupillary component, extraocular movement, and eyelid elevation in that rostrocaudal order.
  • So small vascular insult involving the caudal region of the oculomotor fascicles can present with the above clinical patterns.
  • Oculomotor nuclear lesion leads to bilateral ptosis. Lesions in the cavernous sinus lead to ophthalmoplegia with the involvement of third, fourth and sixth nerves as well.
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7
Q

A 58-year-old woman originally presented six months ago with complaints of pulsatile blurring of her vision, a subjective pulsatile orbital bruit, and headache. She was found to have a low-flow indirect carotid-cavernous fistula. Her inferior petrosal sinus was in discontinuity with her jugular system, so transfacial catheterization of the superior ophthalmic vein was attempted. After two unsuccessful attempts, she is scheduled for direct cannulation and told to perform carotid compression in the interim. In the preoperative holding area, she reports that she has been symptom-free for over two weeks. Which of the following is the next best step in management?
1. Attempt transvenous embolization via transfacial catheterization again. Since she is improving, the likelihood of success is now higher
2. Continue with the scheduled procedure to provide definitive treatment and closure of her fistula
3. Cancel the procedure and suggest careful surveillance since her fistula may have resolved
4. Cancel the operation and schedule her for stereotactic radiosurgery

A

3. Cancel the procedure and suggest careful surveillance since her fistula may have resolved

  • Anywhere from 10% to 60% of carotid cavernous fistulas will spontaneously resolve completely. Low-flow indirect fistulas may be more likely to resolve without intervention. In these settings, intervention is unnecessary.
  • It is important to perform a history and physical on each patient with a carotid cavernous patient before an operation is performed. Given the high rate of spontaneous resolution, a procedure may be unnecessary.
  • The role of compression therapy in the management of carotid cavernous fistulas remains unclear. Up to 30% of persistent low- flow, indirect lesions will resolve with conservative management; however, the impact of compression therapy is not known.
  • Stereotactic radiosurgery is a noninvasive treatment for carotid cavernous fistulas. However, this often involves a latent period and has lower efficacy compared to endovascular intervention. In this case, the resolution of symptoms supports surveillance, not a transition to a different treatment modality.
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8
Q

A 67-year-old male is discussed in the head and neck interprofessional meeting. He has presented with a biopsy- proven squamous cell carcinoma (SCC) on the apex of his scalp measuring 5 cm in diameter. It had been growing over the last 6 month prior to him seeking medical help. CT imaging shows a deep lesion but that the underlying skull appears unaffected. What is the best course of action from the options stated below?
1. Excise the lesion with appropriate margins and close with a rotational flap
2. Excise the lesion with appropriate margins and examine the bone below; if the bone is uninvolved close with a full-thickness skin graft
3. Excise the lesion with appropriate margins and examine the bone below; if the bone is uninvolved close with a split-thickness skin graft
4. Excise the lesion with appropriate margins and close with a free flap

A

3. Excise the lesion with appropriate margins and examine the bone below; if the bone is uninvolved close with a split-thickness skin graft

  • Risk factors for SCC of the scalp include long term sun exposure, having fair skin (low Fitzpatrick skin types), chronic lesions, and immunosuppressed patients.
  • The depth of invasion is an important prognostic factor for survival, with dural and brain parenchyma involvement being considered inoperable.
  • Calvarial involvement requires bone to be drilled or removed. Often with large SCC scalp lesions, sentinel lymph node biopsying is done. This will help to decide on adjuvant therapy.
  • Split-thickness skin grafting (STSG) would be ideal with the large defect caused here. The take rate is higher in STSG due to the graft’s lower metabolic requirements. As this defect is down near to bone the vascular bed left behind the following excision will be poor, making a full-thickness skin graft more likely to fail. A dermatome is used to take donor skin from the thigh. The patients often require postoperative radiotherapy, but this requires further discussion at the interprofessional team meeting.
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9
Q

A 65-year-old male sustained a fracture of the atlas during a motor vehicle accident. The patient is stabilized in the emergency department and is scheduled for a posterior instrumented fusion between the C1 and C2 vertebrae. Which of the following will decrease the risk of vertebral artery injury?
1. Transarticular screw fixation at the level of C1-C2
2. Exposing 2.0 centimeters of the posterior arch of C1 for better visualization
3. Dissecting less than 1.5 centimeters of the posterior arch of the atlas
4. Dissecting less than 3.0 centimeters of the posterior arch of the atlas

A

3. Dissecting less than 1.5 centimeters of the posterior arch of the atlas

  • The vertebral artery is located approximately 1.5 centimeters from the posterior arch of the atlas. Transarticular screw placement at the level of C1-C2 carries a higher risk of vertebral artery injury than a fixation with lateral mass screws to C1 and pedicle screws to C2.
  • While exposing the posterior arch of C1, the surgeon should avoid dissecting past 1.5 centimeters from the midline to avoid injury to the vertebral arteries.
  • The vertebral arteries travel from the lateral aspect of the vertebrae to the medial vertebrae, over the superior aspect of the posterior arch of C1. Exposing less than 1.5 centimeters while dissecting will prevent the surgeon from damaging the vertebral arteries.
  • During placement of C1 lateral mass screws, the screw should be angled 10-15 degrees medially to avoid the vertebral artery, which courses laterally.
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10
Q

A 65-year-old male with diabetes mellitus, chronic kidney disease, and hypertension was recently hospitalized with bacteremia stemming from a urinary tract infection. His hospital course was complicated with persistent low back pain led to an MRI being performed. Which of the following risk factors is this patient at greatest risk?
1. Age of this patient
2. History of diabetes
3. History of chronic kidney disease
4. Hypertension

A

2. History of diabetes

  • Diabetes is the greatest risk factor for discitis in this patient.
  • Discitis is more common in the pediatric population than in adults.
  • Although chronic kidney disease, cirrhosis, and intravenous drug abuse are risk factors, diabetes is the most common.
  • Discitis is more common in males than in females.
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11
Q

A 35-year-old woman with no significant past medical history presents for the evaluation of a pituitary mass found incidentally on MRI brain imaging done after a recent motor vehicle collision. The pituitary mass is described as 1.1 x 0.9 x 0.9 cm, homogeneous enlargement of the pituitary without compression of the optic chiasm. The patient has no complaints. Medications include calcium and vitamin D as she is breastfeeding. She delivered a healthy baby three months ago. Lab work reveals normal TSH of 2.2 microU/ml, free T4 0.9 ng/dl, and prolactin 89 ng/ml. Other pituitary hormones are within normal limits. What is the most likely diagnosis?
1. Prolactinoma
2. Nonfunctioning macroadenoma
3. Pituitary hyperplasia
4. TSH-secreting adenoma

A

3. Pituitary hyperplasia

  • Pituitary hyperplasia on MRI brain appears as a homogeneous enlargement of the gland.
  • Pituitary hyperplasia can be a normal response to physiological stimulation during adolescence, pregnancy, and lactation or as a pathological condition.
  • During pregnancy and lactation, striking hypertrophy of the pituitary can occur. The gland commonly reaches a height of 10 mm by the third trimester and obtains maximal height of 12 mm in the first postpartum week.
  • Pregnancy and lactation cause a physiologic elevation in prolactin. In prolactinoma, prolactin levels are usually more than 200 ng/ml.
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12
Q

A 61-year-old male with a past medical history of type 2 diabetes mellitus for the past 20 years has been having burning pain in his right calf and lateral foot for the past few months. On examination, the posterolateral aspect of the leg is tender to palpation. After nerve conduction studies are performed, it is determined that the cutaneous nerve formed by branches of both the tibial nerve and common peroneal nerve has been impinged. Where should the surgeon incise to decompress the nerve?
1. Between the dorsalis pedis artery and medial malleolus
2. Between the medial malleolus and the Achilles tendon
3. The plantar fascia
4. The superficial sural aponeurosis

A

4. The superficial sural aponeurosis

  • Entrapment of the sural nerve is most often caused by fascial thickening at the site where the nerve becomes superficial to the gastrocnemius, called the superficial sural aponeurosis.
  • The sural nerve supplies sensation to the medial and lateral aspects of the foot on either side of the heel.
  • The sural nerve distally runs in between the lateral malleolus and Achilles tendon, 2.5 cm posterior to the lateral malleolus.
  • In patients with peripheral neuropathy that has no clear underlying cause, a sural nerve biopsy may be helpful in discovering the histopathological etiology.
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13
Q

A 37-year-old female patient with multiple sclerosis had an initial presentation 5 years ago with optic neuritis that completely resolved without treatment. Three years ago, she had sensory and motor involvement of the upper extremities and was treated with corticosteroids. Two years ago, she was treated with interferon beta-1A. Three days ago, she developed the decreased sensation of the left lower trunk without tingling, pain, gait problems, bowel or bladder problems, or systemic symptoms. Exam shows normal visual fields with a right afferent pupillary defect. There is decreased sensation to light touch over the right trunk. Rapid alternating movements, finger tapping, heel tapping to the shin, and finger to the nose are all-normal. What is the most appropriate management for this patient at this time?
1. Corticosteroids
2. Fingolimod
3. Interferon beta-1B
4. Azathioprine

A

1. Corticosteroids

  • The patient has a flare-up of multiple sclerosis (MS) and would be most effectively treated with corticosteroids.
  • The long-term outcome may not be affected, but this treatment will usually reduce the severity and length of the flare-up.
  • The other options are used to prevent MS exacerbations but are not used for acute flare-ups.
  • Another option for acute flare is plasmapheresis. It is an option when corticosteroids are ineffective or contraindicated.
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14
Q

A 50-year-old man suddenly fell on the roadside while walking. He does not obey when told to open his eyes and say his name. When pain is applied to his trapezius, he tries to move away. What is his most likely AVPU (alert, verbal, pain, unresponsive) score?
1. A
2. V
3. P
4. U

A

3. P

  • The AVPU scoring scale is a simplification of the Glasgow coma scale.
  • The score is defined as A= alert, V= response to verbal stimuli, P= response to painful stimuli, U= unresponsive.
  • Since the patient is responding to pain only, he should be given a score “P.”
  • Alert corresponds to GCS of 15; voice responsive corresponds to GCS of 12, pain responsive corresponds to GCS of 8, and unresponsive corresponds to GCS of 3.
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15
Q

A 27-year-old female with a history of otitis media presents with white otorrhea in the right external auditory canal and diminished hearing. An otologic exam reveals white debris in the posterosuperior tympanic membrane quadrant. A CT of the temporal bones was performed. Which of the following findings necessitates MR imaging in this case?
1. Soft tissue mass
2. Ossicular erosion
3. Breached tegmen tympani
4. CNVII canal dehiscence

A

3. Breached tegmen tympani

  • Cholesteatoma is a soft tissue mass composed of proliferating stratified squamous epithelium and anucleated keratin debris, often caused by chronic middle ear inflammation. While the lesions are benign, they can erode into the CNS and cause severe complications.
  • Cholesteatoma appears pearly on gross examination. It may present with aural discharge, conductive hearing loss, otalgia, and Tullio phenomenon.
  • CT demonstrates soft tissue extending from the right external auditory canalto the right epitympanum with blunting of the scutum, widening of Prussak space, and mild ossociular erosion. There is also thinning of the tegmen tympani, which may require MRI to exclude intracranial complications such as venous sinus thrombosis, meningitis, and epidural abscess.
  • Treatment may involve tympanomastoidectomy with or without ossicular reconstruction. The two major types of mastoidectomies performed are canal wall up (CWU) and canal wall down (CWD), the latter of which results in lower rates of recurrence.
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16
Q

A 25-year-old male was recently diagnosed with cluster headache. He is admitted with a persistent headache and excessive lacrimation that is refractory to pharmacologic intervention. Vidian neurectomy was performed to treat this complication. Which of the following is the most susceptible structure to be injured during this procedure?
1. Greater petrosal nerve
2. Geniculate ganglion
3. Carotid sinus
4. Superior salivatory nucleus

A

1. Greater petrosal nerve

  • The greater petrosal nerve fuses with the deep petrosal nerve in the Vidian canal. The Vidian canal is formed in the bony process of the foramen lacerum.
  • The greater petrosal nerve, also known as the large superficial petrosal nerve, is a nerve in the skull that branches from the facial nerve (CN VII).
  • The greater petrosal nerve forms part of a chain of nerves that innervate the lacrimal gland. The fibers have synapses in the pterygopalatine ganglion (also known as the sphenopalatine ganglion). Geniculate ganglion gives rise to the greater petrosal nerve, which passes to the foramen lacerum.
  • The greater petrosal nerve carries parasympathetic preganglionic fibers from the facial nerve to the lacrimal gland. The superior salivatory nucleus, located in the pons, gives rise to the pre-ganglionic para-sympathetic fibers.
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17
Q

A 40-year-old male presents to the clinic with paresthesia to the dorsal surface of his hand. He works as a carpenter and while he is at work he is continuously using a screwdriver every day. His symptoms are caused by compression of the terminal branches of the nerve originating from the posterior cord of the brachial plexus. Which two tendons are compressing this nerve?
1. Brachioradialis and extensor carpi radialis longus
2. Brachioradialis and flexor carpi radialis
3. Brachioradialis and abductor pollicis longus
4. Brachioradialis and extensor pollicis brevis

A

1. Brachioradialis and extensor carpi radialis longus

  • Wartenberg syndrome (cheiralgia paresthetica) results from the compression of the superficial branch of the radial nerve.
  • At approximately 9 cm proximal to the styloid process, the superficial radial nerve passes through the deep fascia of the forearm. It emerges between the brachioradialis and extensor carpi radialis longus to eventually become subcutaneous.
  • Pronation crosses the extensor carpi radial longus beneath the brachioradialis, which can lead to compression of the nerve. Repetitive action such as supination and pronation or hyperpronation can lead to Wartenberg neuritis.
  • The radial nerve originates from the posterior cord of the brachial plexus
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18
Q

A 34-year-old woman presents to the emergency department after a motor vehicle collision. She was a restrained passenger and now complains of severe abdominal pain as well as pain in her back. She has fully intact sensation in bilateral lower extremities and demonstrates 5/5 strength in ankle plantarflexion and dorsiflexion. Straight leg raise is limited by back pain. The rectal tone is good. A CT scan is obtained, and a midsagittal slice is shown below. What is the mode of failure of the posterior spinal column of this patient?
1. Compression
2. Shear
3. Tension
4. Torsion

A

3. Tension

  • A chance fracture of the spine is a flexion-distraction injury of the spine where the anterior spinal column fails in compression, and the middle and posterior spinal columns fail under tension.
  • The center of rotation for a bony chance fracture is through the abdominal viscera.
  • There is a high association with gastrointestinal injuries with chance fractures (50%).
  • Disruption of the posterior spinal ligamentous elements necessitates surgical fixation, but bony chance fractures are stable injuries. The abdominal injuries may necessitate further workup.
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19
Q

A 4-year-old boy is brought to the emergency department after an accidental fall from a bike. The child is active, playful, and tolerating oral feeds normally. A reconstructed image from the patient’s CT head is shown in the figure. Which of the following is the next best step in the management of this patient?
1. Cranioplasty
2. Bone cement repair
3. Venogram study
4. Reassurance

A

4. Reassurance

  • The reconstructed 3D CT image is characteristic of an unossified lambdoid suture in the child.
  • It is a normal anatomical variation and does not require any surgical management.
  • The lambdoid suture may remain patent until the child reaches adulthood.
  • A venogram is justified in cases with compound depressed fractures overlying the transverse sinus. Mesh repair is justified in significant bony defects following compound comminuted depressed fractures.
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20
Q

An adolescent patient presents to the office for initial evaluation after the school nurse noted a thoracolumbar prominence on routine scoliosis screening. Diagnostic imaging reveals findings compatible with Scheuermann disease. Which of the following radiographic findings is most characteristic of this diagnosis?
1. Compression fracture deformity of the thoracic vertebrae
2. Vertebral body wedging in at least three adjacent levels (greater than 5 degrees)
3. Disk space narrowing with herniations at multiple adjacent levels
4. Endplate sclerosis and osteophytic lipping at multiple adjacent levels

A

2. Vertebral body wedging in at least three adjacent levels (greater than 5 degrees)

  • Kyphosis most commonly occurs in the thoracic spine.
  • Radiographic imaging may also note endplate narrowing and Schmorl’s nodes.
  • Scheuermann disease is defined as vertebral body wedging of greater than 5 degrees in at least three contiguous vertebrae.
  • Correction of kyphosis by hyperextension of the vertebrae rules out Scheuermann disease.
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21
Q

A 70-year-old female came to the emergency department with right-sided weakness and Broca aphasia. Her last known normal is 16 hours ago. NIH stroke scale is 16. Based on the recent advancements in stroke care, which of the following perfusion CT prompt one to take for mechanical thrombectomy?
1. Cerebral blood volume and cerebral blood flow are decreased
2. Cerebral blood flow less than 10 ml/100 g/min
3. Decreased cerebral blood volume
4. Increased mean transit time and decreased cerebral blood flow

A

4. Increased mean transit time and decreased cerebral blood flow

  • In an infarcted area of brain tissue, cerebral blood volume and cerebral blood flow are decreased.
  • Cerebral blood flow less than 10 ml/100g/min is an infarcted tissue already.
  • Decreased cerebral blood volume is used for identifying core
  • The penumbra is the area of ischemia surrounding the infarct site with Increased mean transit time, cerebral blood volume increased, and decreased cerebral blood flow
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22
Q

A 38-year-old man presents to the emergency department after a motor vehicle collision. He was a restrained passenger and now complains of severe abdominal pain as well as pain in his back. His rectal tone is good and displays no bowel or bladder incontinence. He has a fully intact sensation in the bilateral lower extremities. Straight leg raise is limited by back pain. A CT scan is obtained, and a midsagittal slice is shown below. What is the mode of failure of the anterior spinal column?
1. Compression
2. Shear
3. Tension
4. Torsion

A

1. Compression

  • A Chance fracture of the spine is a flexion-distraction type injury centered at the abdominal viscera.
  • A Chance fracture of the spine is a flexion-distraction injury of the spine where the anterior spinal column fails in compression, and the middle and posterior spinal columns fail under tension.
  • There is a very high association of gastrointestinal injuries associated with Chance fractures.
  • Bony chance fractures, as seen above, are stable injuries and can be treated non-operatively. However, ligamentous chance fractures require surgical fusion.
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23
Q

A 34-year-old woman is brought to the hospital by ambulance after sustaining a head injury resulting in loss of consciousness in a car accident. She regained consciousness and recalls events leading up to the accident but is confused about what happened after. She knows where she is, what year it is, and recalls her name and date of birth without difficulty. The patient reports headache 10/10 with mild nausea but no vomiting. She denies any focal weakness in upper or lower extremities, tingling, numbness. Her physical exam shows a 6 cm swelling on the occipital scalp, tender to touch with bruising and intact skin. Eyes are equal and reactive to light bilaterally. The uvula is midline, CN II-XII are intact, with motor and strength 5/5 in upper and lower extremities. Clinically the patient seems to have a concussion with a contusion at the site of impact. Which of the following is the next best step in the management of this patient?
1. CT maxillofacial
2. CT head and cervical spine with contrast
3. CT head and cervical spine without contrast
4. MRI head

A

3. CT head and cervical spine without contrast

  • CT head and cervical spine can rule out serious traumatic injury.
  • Simple concussions do not typically show up on the CT scan in the first 24-48 hours. Whiplash injury of the cervical spine can result in a muscle spasm in which the normal curvature, lordosis, of the cervical spine is straightened.
  • CT scan will rule out more serious injuries such as a skull fracture, brain hemorrhage, or subdural hematoma, epidural hematoma.
  • CT maxillofacial does not provide full imaging of the brain and is useful for facial fractures. CT head without contrast should be performed to rule out more serious, life-threatening traumatic injuries. CT with IV contrast is not essential but should be used in cases where there is a high suspicion of intracranial/intraparenchymal hemorrhages.
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24
Q

A highly obese 53-year-old female presents to the clinician with a history of right-sided facial (Bell’s) palsy for almost a month. She also complains of difficulty in chewing and swallowing food. Her history is significant for uncontrolled diabetes and hypertension. On examination, her vitals include a blood pressure of 174/100 mmHg, a pulse of 85 beats per minute, respiration of 16 breaths per minute, and a temperature of 98 degrees Fahrenheit. Her random blood glucose was 376 mg/dl. On further examination, the clinician noticed that the problem in swallowing is because of the paralysis of one of the muscles of the suprahyoid region on the right side which is affected due to a lesion in the facial nerve that is supplying it. What is this muscle that is most likely paralyzed?
1. Mylohyoid muscle
2. Geniohyoid muscle
3. Omohyoid muscle
4. Stylohyoid muscle

A

4. Stylohyoid muscle

  • The suprahyoid muscles include digastric, stylohyoid, geniohyoid, and mylohyoid.
  • The stylohyoid muscle and the posterior belly of the digastric muscle are innervated by the facial nerve (VII cranial nerve).
  • The stylohyoid muscle helps in the elevation of the tongue and elongates the floor of the mouth and helps in deglutition.
  • The Geniohyoid muscle is supplied by the first cervical nerve via the hypoglossal nerve. The mylohyoid muscle and anterior belly of the digastric muscle are innervated by the mandibular branch of the trigeminal nerve.
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25
Q

A 35-year-old woman presents to the neurology clinic following persistent headaches and progressive diminution of her vision. Her fundoscopic exam revealed bilateral early optic atrophy. The image of her MRI brain is shown. The symptoms in the patient were refractory to medical management. Which of the following modality is most effective in the management of the patient?
1. Optic nerve fenestration
2. Bariatric surgery
3. Ventriculoperitoneal shunt
4. Veno-sinus stenting

A

4. Veno-sinus stenting

  • The patient has clinical and radiological features (empty sella syndrome) consistent with idiopathic intracranial hypertension (IIH).
  • Venous sinus narrowing and stenosis are now considered to play an important and curable role in the pathogenesis of IIH.
  • Veno-sinus stenting has shown to have the best clinical and visual benefits among various forms of operative interventions considered for IIH.
  • The optic nerve fenestration has benefits in managing visual diminution. Bariatric surgery is considered among patients with a normal venogram study.
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26
Q

A 54-year-old female presents with a complaint of slurred speech for the past two days. She also noticed poor coordination in her left leg and trouble gripping her left hand when she went home last night. In addition, she was drooling out the left side of her mouth. At the time of assessment, she reports having the worst headache ever. She notes that the pain is generalized but states that it is 10/10 in severity. She has a history of mitral valve replacement and is anticoagulated with warfarin. CT head without contrast is shown. She was given prothrombotic complex concentrate (PCC) after having supra-therapeutic INR > 5 on warfarin which later came down to 2.0. What is the next best step in the management of this patient?
1. Monitor the progression of hematoma expansion and hold reversal agents
2. Give a dose of PCC or Fresh Frozen Plasma with Vitamin K to reduce INR 1.3
3. Give a dose of a reversal and check the INR
4. Give vitamin K only and monitor the progression of hematoma with daily CT head for the next 72 hours

A

2. Give a dose of PCC or Fresh Frozen Plasma with Vitamin K to reduce INR 1.3

  • Monitoring the hematoma expansion is the next step after achieving the target INR with a reversal agent.
  • The goal of reversal agents is to achieve a target INR 1.3 to avoid hematoma expansion. If the repeat INR after 6 hours of a previous reversal agent is still >1.3, the repeat dose of either PCC or FFP is required.
  • INR should be checked every four to six hours for the first 24 hours and then checked daily for a few days.
  • Vitamin K is always given with FFP, PCC, or Factor VII for warfarin-associated intracranial hemorrhage. Vitamin K has a delayed onset of action compared to PCC and FFP but achieves a steady decrease in INR over the next 12 to 24 hours compared to PCC or FFP alone.
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27
Q

A 30-year-old man presents with head trauma after an assault. On physical exam, there is bruising over the right mastoid process. A CT of the temporal bones is performed. Which of the following structures is most likely injured?
1. Facial nerve
2. Lateral semicircular canal
3. Internal carotid artery
4. Incudomalleolar joint

A

4. Incudomalleolar joint

  • Temporal bone fractures typically result from high-impact blunt head trauma. The temporal bone has complex anatomy including four geographic parts (squamous, mastoid, petrous, tympanic) and numerous named foramen/canals (foramen lacerum, carotid canal, internal acoustic meatus, jugular foramen).
  • Common associated injuries include hearing loss, facial palsy, extra-axial hemorrhage, and cerebral contusion.
  • In this case, CT demonstrates a longitudinal fracture of the right temporal bone with ossicular chain disruption. Temporal bone fractures that violate the otic capsule have a much higher association with CSF leak, sensorineural hearing loss (SNHL), and certain intracranial pathology.
  • Treatment and management of associated life-threatening, intracranial pathology should be the primary focus. Formal audiological evaluation is deferred several weeks post-injury to ensure edema and hemotympanum have completely resolved.
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28
Q

A patient presents to the clinic with complain of back pain. On history, the patient reveals that he experiences shooting pain from his buttocks to the leg since he fell from stairs 2 weeks ago. A complete neurological exam was conducted by the clinician and MRI of the lumbosacral region was advised. MRI shows the impingement of the anterior nerve root at L5. What would be an indication for surgical repair of the problem?
1. A weakness of the ipsilateral lower extremity and shooting leg pain.
2. Immediate surgical intervention is required, no matter if the patient is symptomatic.
3. Persistent, intractable pain following exhaustion of all possible nonoperative treatment options (physical therapy, rest, NSAIDs).
4. Whenever the patient electively chooses to have surgery performed.

A

3. Persistent, intractable pain following exhaustion of all possible nonoperative treatment options (physical therapy, rest, NSAIDs).

  • The most common indication for surgical intervention is persistent, intractable pain following exhaustion of all possible nonoperative treatment options (physical therapy, rest, NSAIDs) for a minimum of a dedicated 6 week period.
  • Even in the setting of acute injuries with MRI evidence of a lumbar disc herniation and correlating clinical symptoms in the motor/sensory distribution of the specific nerve root(s) involved, nonoperative management remains the mainstay of initial treatment.
  • Greater than 95% of lumbar disc herniations involves the L4/L5 and/or L5/S1 disc spaces, with patients typically presenting with low back pain with sharp, stabbing pain often traceable form the lower lumbar region to the lower leg and foot.
  • Lower extremity radiculopathy, often ambiguously ill-defined even by healthcare providers and physicians as “Sciatica,” is often attributable to nerve root(s) compression and impingement at one or multiple nerve roots in the lumbosacral plexus. These roots ultimately contribute innervation (motor/sensory) peripherally as the sciatic nerve, manifests as shooting, stabbing, and/or burning pain radiating from the back to the ipsilateral or contralateral lower extremity.
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29
Q

An 80-year-old man with a history of coronary artery disease presents with one day of confusion and aphasia. An MRI of the brain is performed. Which of the following is the most likely diagnosis?
1. Arterial ischemia
2. Deep venous thrombosis
3. Wernicke encephalopathy
4. Acute disseminated encephalomyelitis

A

1. Arterial ischemia

  • Thalamic infarcts are often the result of vertebrobasilar disease. Rarely, occlusion of the artery of Percheron (common vascular trunk that arises from one P1 segment) can be causative.
  • Presentation depends on the region affected and may include cognitive/behavioral disturbances, aphasia, hemineglect, ophthalmoplegia, and sensorimotor deficits.
  • In this case, DWI demonstrates small areas of restricted diffusion in bilateral central thalami, which do not appear engorged.
  • Thalamic infarcts are often managed medically. Outcome is usually positive with return to baseline neurological function.
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30
Q

A 40-year-old man presents with a nine-month history of lower back pain. The pain is constant and affecting his ability to exercise and is aggravated when he sits for long periods, with coughing and sneezing. It is located in the midline at approximately the L5 level. His past medical history includes radicular pain, which has decreased. He has done three months of a core-based physical therapy program without much improvement, and three epidural steroid injections that yielded only three weeks of relief each time. An MRI demonstrates L4-5 moderate disc degeneration with a posterior high-intensity zone and bulge. A procedure to determine if the disc is the origin of the patient’s chronic spine pain prior to an L4-5 total disc arthroplasty is performed (see below). What position should be patient be in for this procedure?
1. Supine
2. Prone
3. Sitting
4. Standing

A

2. Prone

  • A provocative discography (PD) is an invasive diagnostic spine procedure. Contrast is administered into the nucleus pulposus of an intervertebral disc. The test is based on the premise that discs can be a source of spine pain, and symptomatic, internally disrupted disc causes pain when it is mechanically loaded; therefore, it should be similarly painful when pressurized with injected contrast.
  • PD should only be employed when there is a moderate to high pretest probability that the spine pain is suspected to be of discogenic origin. This is based on history and advanced imaging findings. The information obtained from the test will be used to rule out or plan subsequent treatment decisions such as therapeutic intradiscal procedures (e.g., intradiscal electrothermal therapy, annuloplasty, regenerative medicine) or surgery (e.g., disc arthroplasty, interbody fusion).
  • PD is performed in a procedural suite with x-ray fluoroscopy. The patient is positioned prone, except in the case of cervical discography where they are supine.
  • Several decades have passed since the advent of PD. Arguably it is the best method to determine with reasonable certainty the presence or absence of discogenic spine pain.
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31
Q

A 6-year-old male with a long history of trouble with coordination presents to the office. Based on the results of the brain MRI, the pediatrician explains that the patient presents a malformation that is associated with vermian and cerebellar hypoplasia. Which of the following complications is most associated with this malformation?
1. Hydrocephalus
2. Facial malformations
3. Seizures
4. Gastrointestinal bleeding

A

1. Hydrocephalus

  • Dandy-Walker is comprised of hypoplasia of the cerebellar vermis, dilation of the 4th ventricle, and elevation of the cerebellar tentorium.
  • 70-90% of patients with Dandy-Walker malformation present hydrocephalus.
  • Dandy-Walker is also associated with malformations of the face, limbs, heart
  • DWM may be isolated or associated with chromosomal abnormalities, Mendelian disorders, syndromic malformations, congenital infections, and various other comorbidities.
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32
Q

A 42-year-old woman presents to the emergency department after a motor vehicle collision complaining of back pain. She was a restrained passenger. She has fully intact sensation in bilateral lower extremities and demonstrates 5/5 strength in ankle plantarflexion and dorsiflexion. Straight leg raise is limited by back pain. The rectal tone is good. A CT scan is obtained, and a midsagittal slice is shown below. What are associated injuries most concerning for this patient?
1. Abdominal visceral injuries
2. Chest wall injuries
3. Closed head injuries
4. Long-bone fractures

A

1. Abdominal visceral injuries

  • A Chance fracture of the spine is a flexion-distraction injury of the spine with the center of rotation at the abdominal viscera where the anterior spinal column fails in compression, and the middle and posterior spinal columns fail under tension.
  • Chance fractures have a very high (50%) association with gastrointestinal injuries due to the center of rotation being at the abdominal viscera.
  • A thorough gastrointestinal examination is warranted in all cases of bony chance fractures, and patients with any signs of abdominal trauma due to seatbelt injuries.
  • Bony chance fractures, as seen in this image, can be managed non-operatively, whereas ligamentous chance fractures necessitate surgical stabilization.
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33
Q

A 55-year-old male was brought into the emergency room with right hemiplegia and loss of consciousness. GCS was E1M5V1. The pupil on the left side was 3 mm and nonreactive. CT brain showed large hyperdensity in the left basal ganglia and ventricles, with mass effect and midline shift of 8mm. What will be the ideal treatment?
1. Intubation, hyperventilation with sedation, and hemostatic therapy alone
2. Intubation, hyperventilation with sedation, hemostatic therapy, and mannitol
3. Intubation with sedation, hyperventilation, mannitol, and decompressive craniectomy
4. Expectant line of management

A

3. Intubation with sedation, hyperventilation, mannitol, and decompressive craniectomy

  • Since the patient has large ICH with edema, mass effect, and midline shift, he requires maximum antiedema measures.
  • Decompressive craniectomy, evacuation of hematoma, and expansive duraplasty improve outcomes in patients with large hematoma and coma with GCS below 8.
  • Intubation should be with sedation; otherwise, intracranial pressure will rise further.
  • Hyperventilation should be to maintain a pCO2 of 28 to 32 mmHg.
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34
Q

A 32-year-old woman presents after a fall on an icy sidewalk where she hit her head and lost consciousness for several minutes. Her vital signs show oxygen saturation of 98% on room air, respiratory rate of 20 per minute, heart rate of 55 beats per minute, blood pressure of 140/90 mmHg, and temperature of 36.7 C (98 F). On examination, she is awake and alert and complains of a severe headache. There are no cranial nerve, motor, or sensory deficits. Babinski sign is positive on the right side. The patient undergoes a CT scan (see below). In which cranial nerve would the patient be likely to develop a deficit?
1. CN I
2. CN III
3. CN IV
4. CN VI

A

2. CN III

  • The CT scan shows a subdural hematoma with subarachnoid hemorrhage on the right. The complication would include an increase in the size of the hemorrhage as well as edema of the right temporal lobe. This may predispose to herniation of the medial temporal lobe leading to uncal herniation.
  • Uncal herniation compresses CN III. The clinical presentation consists of a dilated ipsilateral pupil, which does not respond to light. On further compression, the affected eye will be looking down and out.
  • Further herniation may compress the brainstem and cause a decrease in sensation.
  • The uncus and the adjacent temporal lobe slide down the tentorial incisura and compress the posterior cerebral arteries and the brain stem. It carries a poor prognosis.
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35
Q

A 16-year-old with no significant past medical history presents to the emergency department with vomiting and severe headache preceded by a two-minute episode of a generalized tonic-clonic seizure 2 hours prior. He is accompanied by his mother who states that he has complained of occasional headaches for the past 3 years. His blood pressure is 90/60 mmHg, pulse rate is 110/min, and respiratory rate is 28/min. On physical examination, he is in moderate distress due to a headache and has evidence of lacerations on his tongue. He does not have any appreciable focal neurologic deficits. Where would you expect to find a lesion on magnetic resonance imaging (MRI) of this patient?
1. Cerebrum
2. Pons
3. Brain stem
4. Internal capsule

A

1. Cerebrum

  • This patient has an arteriovenous malformation of the brain. Arteriovenous malformations (AVMs) are a developmental anomaly of the vascular system, consisting of tangles of poorly formed blood vessels in which the feeding arteries are directly connected to a venous drainage network without any interposed capillary system.
  • The majority of AVMs of the brain are found in the cerebral hemispheres. Seizures are due to cortical irritation, which would be less likely to occur from a lesion in the pons, cerebellum, or internal capsule.
  • AVMs are the second most common cause of intracranial bleed after cerebral aneurysms, responsible for 10 percent of all cases of subarachnoid hemorrhage.
  • Hemorrhages are usually intraparenchymal but can primarily occur in the subarachnoid space. Symptoms due to hemorrhage include loss of consciousness, sudden and severe headache, nausea, and vomiting as the coagulated blood makes its way down to be dissolved in the individual’s spinal fluid.
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36
Q

A 14-year-old presented with a spinal deformity. Her mother noticed this deformity at the age of 6 years. The deformity progressively increased in size. She is community ambulatory without any pain. She faces difficulty in standing from a sitting posture. She has one younger sibling with the same deformity. The radiograph is shown in the figure. Which of the following is the most appropriate treatment for this patient?
1. Posterior spinal fusion T2-L5
2. Posterior spinal fusion T2-pelvis
3. Anterior spinal fusion T4-L5
4. Posterior spinal fusion T4-pelvis

A

2. Posterior spinal fusion T2-pelvis

  • This patient has clinical and radiological features of scoliosis secondary to Duchenne Muscular Dystrophy. These patients have typical difficulty in standing (Gowers sign). This is an X- linked recessive disease that may present with progressive weakness, scoliosis, equinovarus foot, and cardiomyopathy.
  • The radiograph reveals coronal thoracolumbar scoliosis with pelvic obliquity. There is no hemivertebra which excludes the possibility of congenital scoliosis. Cobb angle is measured from the end vertebra of both curves to plan for surgery.
  • Posterior spinal fusion from T2-sacrum is indicated in this patient. If the pelvic obliquity is more than 15 degrees then fusion should be done to include the sacrum which improves sitting balance and coronal alignment. Proximal fusion should be extended to T2 to prevent junctional kyphosis.
  • If the forced vital capacity (FVC) is greater than 40, the scoliosis is greater than 25 degrees, and a 2-year life expectancy is projected, surgery is recommended. In contrast to a posterior- only technique, an anterior approach to the spine is not recommended in Duchenne patients because it requires lung deflation, which can lead to respiratory difficulties and increased blood loss.
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37
Q

A 27-year-old man is brought to the hospital after being assaulted with a metal pipe to his face. His chief complaint is left-hand side facial pain. His vital signs are within normal limits. On examination, there is edema and subconjunctival hemorrhage. A zygomatic-maxillary complex fracture is suspected. Which of the following is the next best step in the evaluation of this patient?
1. Dental panoramic radiograph
2. Towne view
3. Caldwell view
4. 15/30 occipitomental view

A

4. 15/30 occipitomental view

  • 15/30 occipitomental views are used when a zygomatic- maxillary complex fracture is suspected.
  • Zygomatic arch fractures have four components: lateral orbital wall, orbital floor, zygomatic arch, and the maxilla and zygoma separation.
  • Zygomatic arch fractures are also known as quadripod fractures or quadramalar fractures.
  • The occipitomental view is also known as the Waters’ view, and the x-ray passes from behind the patient’s head toward the radiographic plate.
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38
Q

A 35-year-old postpartum female presents with a progressive headache. On physical exam, there are no cranial nerve deficits. Her gadolinium-enhanced MRI of the brain is shown. Which of the following is the most appropriate therapy?
1. Observation
2. Non-steroidal anti-inflammatory medication
3. Glucocorticoid therapy
4. Surgical resection

A

3. Glucocorticoid therapy

  • Lymphocytic hypophysitis is a rare autoimmune disease of the pituitary gland classically seen in peripartum women with headache or middle-aged men with diapedes insipidus.
  • Lymphocytic hypophysitis may present with pituitary dysfunction, such as central diabetes insipidus, anterior pituitary hormone deficiency, and hypo/hyperprolactinemia. The degree of lymphocytic infiltration corresponds to the degree of pituitary enlargement, which may secondarily cause mass effect and contribute to visual loss, ophthalmoplegia, and headache.
  • Lymphocytic hypophysitis is a diagnosis of exclusion, and histopathology with tissue biopsy is needed for a definitive diagnosis. Clinical information, laboratory data, and imaging, however, can help with the diagnosis. Gadolinium-enhanced MRI of the pituitary is the modality of choice, and may demonstrate an avidly-enhancing, thickened pituitary stalk, enlarged pituitary gland, and loss of the normal posterior pituitary “bright spot”. Gutenberg scoring was developed to correctly distinguish lymphocytic hypophysitis from pituitary adenoma.
  • The main goal of treatment of lymphocytic hypophysitis is to manage pituitary hormone deficiencies and mass effect. Treatment consists of conservative management and anti- inflammatory medication. Surgery is employed for patients suffering from visual problems, compression of nearby structures, or equivocal imagining findings that require histology for diagnosis.
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39
Q

A 65-year-old female presented with the complaint of tingling, pain, and paresthesias over the dorsolateral aspect of her left hand and wrist for the last 1 month. She was administered a steroid injection in her left wrist for her condition. She now has paresthesias to the dorsomedial aspect of her left hand that worsens with wristwatch wear. From which cord of the brachial plexus does the offending nerve originate?
1. Anterior
2. Posterior
3. Medial
4. Lateral

A

2. Posterior

  • The radial nerve comes from the posterior cord of the brachial plexus.
  • Compression of the superficial branch of the radial nerve at the level of the wrist is known as cheiralgia paresthetica. It is also commonly called Wartenberg syndrome or superficial radial nerve palsy.
  • Chordoroff et al. reported a case in which a steroid injection to the 1st dorsal compartment of the wrist for de Quervain tenosynovitis causes subdermal atrophy in the surrounding area which later led to the development of cheiralgia paresthetica from the patient’s wristwatch.
  • Cheiralgia paresthetica causes symptoms such as pain, burning, paresthesia, numbness, etc. to the dorsoradial aspect of the wrist, hand, and fingers.
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40
Q

A 54-year-old woman presents to the clinic with a one-year history of progressive swallowing difficulties. An MRI is obtained showing a T2 fat saturation hyperintense lesion as pictured. A needle biopsy is performed, which shows bubbly cells separated into lobules with fibrous septa and a myxoid stroma. Which of the following is the best initial therapy for this patient?
1. Neoadjuvant radiation therapy
2. Chemotherapy
3. Conventional photon radiation
4. Highly-conformal radiotherapy

A

4. Highly-conformal radiotherapy

  • Chordomas are relatively radioresistant which necessitates high-dose radiation including proton beam radiation or radiosurgery (highly conformal radiotherapy).
  • When a needle biopsy is performed, the surgical resection should include the needle tract as chordomas can seed the needle biopsy tract.
  • En bloc resection followed by high-dose radiation provides the best current long-term outcomes for chordoma treatment.
  • Chordomas are slow-growing and chemotherapy is not a generally used treatment strategy. If chemotherapy is given, it is usually given as part of a clinically trial.
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41
Q

A 65-year-old man presents to the neurology clinic following acute onset blurring of his vision. The neurological examination revealed defects in the perception of color, form, and movement of objects. He is under medication for symptomatic dilated cardiomyopathy. Which of the following is the most likely anatomical region of involvement in the patient presenting with such neurological signs and symptoms?
1. Brodmann area 17
2. Brodmann area 22
3. Brodmann area 40
4. Brodmann area 45

A

1. Brodmann area 17

  • The patient likely has an acute ischemic stroke in the occipital cortex secondary to dilated cardiomyopathy.
  • The defect in his perception of color, form, and movement of an object indicates the involvement of his primary visual cortex.
  • Brodmann area 17 represents the primary visual cortex in the brain.
  • Brodmann area 22 controls the lexical-semantic processing of sound. Brodmann area 40 is the supramarginal gyrus, and damage to this region can lead to alexia and agraphia.
42
Q

A 48-year-old man is brought to the emergency department after a motor vehicle collision complaining of back pain but denies any abdominal pain and has no evidence of seatbelt sign. He reports fully intact sensation in bilateral lower extremities and demonstrates 5/5 strength in ankle plantarflexion and dorsiflexion. Straight leg raise is limited by back pain. The rectal tone is good. A radiograph is obtained and shown below. What is the most appropriate management strategy for this patient?
1. Immobilization in a cast or TLSO brace
2. Surgical decompression only
3. Surgical decompression and fusion
4. Surgical fusion without decompression

A

3. Surgical decompression and fusion

  • While bony chance fractures are considered stable and may be managed non-operatively in the absence of a neurological deficit, ligamentous chance fractures, as seen here that disrupt the posterior ligamentous complex, are unstable and should be treated with surgical decompression and fusion.
  • A Chance fracture of the spine is a flexion-distraction injury of the spine where the anterior spinal column fails in compression, and the middle and posterior spinal columns fail under tension.
  • The center of rotation of chance fractures is through the abdominal viscera, and there is a high incidence in restrained passengers. Therefore, abdominal injuries must be also ruled out.
  • Disruption to the posterior ligamentous complex renders the spine unstable, and stabilization must be provided surgically.
43
Q

A 65-year-old man presented to the emergency department with severe neck pain following a slip and fall in the bathroom. He had severe axial neck pain, which worsened on neck rotations. His neurological status was normal, and the rest of the systemic examination was also within normal limits. He has a history of diabetes, hypertension, and ischemic heart disease, for which he underwent coronary angioplasty six years ago. He underwent a detailed evaluation of his cervical spine and was diagnosed with a type 2 fracture of the odontoid process. No other injuries were identified. The fracture was angulated at 10 degrees with a 1 mm fracture gap and 4 mm anteroposterior displacement. Which of the following is the most rational management strategy in the patient?
1. Anterior odontoid screw fixation
2. Halo-vest application
3. SOMI Brace (Sternal Occipital Mandibular Immobilizer)
4. Hard cervical collar

A

4. Hard cervical collar

  • Odontoid fractures are managed conservatively or surgically based on various factors, including the degree of displacement, type of fracture (Anderson and D’Alonzo type 2 mainly), age of the patient, associated injuries, comorbidities, and presence of osteoporosis.
  • Un-displaced fractures, defined as less than 2 mm fracture gap, less than 5 mm anteroposterior displacement, and less than 11- degree angulation, are best managed conservatively.
  • The overall union rates following hard collars and halo-vest immobilization in stable odontoid fractures are reported to be reasonably similar. However, studies have revealed a much better reduction in the cervical range of motion after the halo- vest application. In younger individuals, the use of halo-vest immobilization is typically recommended, although, in the older population, hard cervical collar application is associated with the lowest complication rates.
  • The major complications with halo-vest immobilization in the elderly include infection, aspiration pneumonia, and respiratory failure.
44
Q

A 19-year-old ballet dancer with chronic lower back pain has exhausted non-operative options for treatment of her low-grade lumbosacral spondylolisthesis and underwent the surgical treatment pictured below. There were no intraoperative complications reported. Three weeks later, her lower back pain has improved, but she is complaining of new symptoms of numbness over the anterolateral aspect of her right thigh. What is the cause of this complication?
1. Metalwork penetrating into the nerve root canal
2. Progression of the disease
3. Nerve root injury during the surgical slip reduction
4. Compression of a nerve during prolonged prone positioning intraoperatively

A

4. Compression of a nerve during prolonged prone positioning intraoperatively

  • Meralgia paresthetica is a well-known complication of prone positioning used for the posterior approach to the spine. Insufficient care with positioning of the bolsters may result in pressure over the lateral femoral cutaneous nerve (LFCN) of the thigh, causing numbness in its distribution. Symptoms usually resolve with time but can sometimes become painful while the nerve is recovering.
  • Meralgia paresthetica is typically benign and self-limited with frequent spontaneous remission.
  • Treatment focuses on patient reassurance and ways to reduce pressure and irritation over the nerve and groin region.
  • Medications that may be helpful include nonsteroidal- antiinflammatory drugs (NSAIDs), topical capsaicin, lidocaine, or tacrolimus for epidermal dysesthesia or cutaneous hypersensitivity.
45
Q

A 48-year-old woman presents with chronic headache. She denies fever, vision loss, and facial swelling. Serum prolactin is 200 ng/mL and growth hormone is 6 mcg/dL. An MRI of the brain is shown. Which of the following is the most likely diagnosis?
1. Cavernous sinus thrombosis
2. Meningioma
3. Pituitary adenoma
4. Lymphocytic hypophysitis

A

3. Pituitary adenoma

  • Pituitary adenomas are benign tumors of the adenohypophysis. A macroadenoma is a sellar mass greater than 10 mm without a separate identifiable pituitary gland.
  • Pituitary adenomas are often found incidentally on imaging. Up to 75% are endocrinologically active, and may be prolactin-, growth hormone-, or ACTH-secreting. Visual field defects (bitemporal hemianopsia) may present secondary to mass effect in cases of large tumors. Headache is commonly reported though is nonspecific.
  • In this case, contrast-enhanced T1W MR demonstrates a hypoenhancing mass inseparable from an enhancing and enlarged pituitary gland, with minimal superior extension. The mass contacts and surrounds the right supraclinoid internal carotid artery without compression.
  • Dopamine agonists are the first-line treatment for prolactin- secreting tumors. Transsphenoidal resection is recommended in patients with macroadenomas and visual field deficit, ophthalmoplegia, optic nerve compression, pituitary apoplexy, or loss of endocrine function.
46
Q

A 16-year-old boy is brought to the emergency department after being knocked off his bike by a car. His eyes are closed with clear trauma to his head and a clear, bloodstained fluid running from his nose. He is making no verbal effort and has stertorous breathing. On stimulation of the trapezius, he extends at the elbow with forearm pronation and wrist flexion. His knees extend with internal rotation at the hips and plantar flexion of the feet. What is the most likely location of the lesion causing this patient’s presentation?
1. Bilateral frontal lobes
2. Below the red nuclei
3. Below the vestibular nuclei
4. Cervical spine

A

2. Below the red nuclei

  • Decerebrate posturing is characterized by adduction and internal rotation of the shoulder, extension at the elbows with pronation of the forearm, and flexion of the fingers. The lower limbs show extension and internal rotation at the hip with knee extension and plantar flexion of the feet. Toes are typically abducted and hyperextended.
  • Decerebrate posturing suggests damage to the corticospinal and rubrospinal tracts with the preservation of the vestibulospinal tract. This places the lesion below the red nucleus but above the vestibular nuclei in the rostral medulla. Therefore a pontine lesion is most likely.
  • Overall, children requiring admission to hospital due to head injury have a mortality of 10 to 13%; however, in severe cases with decerebrate posturing, the mortality is 71%. Factors that favor survival in traumatic brain injury with decerebrate posturing include younger patient age, admission within 6 hours of injury, and extradural hematoma. Poorer outcomes are seen in acute subdural hematoma and older age.
  • Clear bloodstained fluid running from the nose of a patient with a head injury likely indicates a base of skull fracture.
47
Q

A 27-year-old female patient with no past medical history presents to the emergency department with left eye pain and decreased perception of light. The exam is also remarkable for poor rapidly alternating movement of the right hand and slurred speech. Both eyes show ocular dysmetria, and tandem gait is very unsteady. On ocular examination, when an attempt is made to gaze contralaterally, the affected eye adducts minimally. The contralateral eye abducts, however, with nystagmus. What is the next step in the management of this patient?
1. Dilated fundoscopic examination
2. Magnetic resonance imaging of the brain and orbits
3. Lumbar puncture
4. EEG

A

2. Magnetic resonance imaging of the brain and orbits

  • Optic neuritis is often the presenting symptom of multiple sclerosis. Another common visual complaint is abnormal eye movement, known as internuclear ophthalmoplegia (INO). Patients often complain of diplopia. INO results from a demyelinating lesion of the medial longitudinal fasciculus.
  • A contrast-enhanced magnetic resonance imaging (MRI) scan is the most appropriate next step in the management of this patient.
  • The presence of typical lesions on an MRI negates the need for lumbar puncture in most cases.
  • A lumbar puncture can be obtained if the MRI is equivocal.
48
Q

A 39-year-old man presents with neck stiffness, bilateral arm pain, difficulty buttoning shirts, and gait instability. He has 4+/5 strength in the upper extremities and is hyperreflexia at his biceps, brachioradialis, and patella. He also has a positive Hoffman sign bilaterally. MRI is shown below. Which of the following is the most rational next step in the management of the patient?
1. CT spine
2. HLA-B27 status
3. Posterior cervical laminectomy
4. Anterior corpectomy and bone graft fusion

A

1. CT spine

  • The clinical and radiological features in the patient are highly suggestive of cervical myelopathy resulting from an ossified posterior longitudinal ligament (OPLL).
  • The CT spine is the most rational next step in the management of the patient presenting with such clinical characteristics.
  • CT spine helps in diagnosing as well as categorizing the patterns of involvement of the vertebral bodies and the disc spaces, thereby helping to formulate the appropriate surgical intervention in the patient.
  • Anterior or posterior surgical approaches in the management of OPLL depend upon its subtypes as classified by the CT findings. It also depends upon the age, neurological status, medical comorbidities, and the cervical lordosis of the patient.
49
Q

A 16-year-old man from Nepal presents to the neurology clinic with worsening headache, low-grade fever, and vomiting for the last three weeks. The relatives noticed three episodes of right focal seizures a week back. He denies any history of intravenous drug abuse or any psychiatric medication use. There is no neck rigidity or neurological deficit on clinical examination. The fundus examination shows Grade 1 papilledema. A further systemic examination is within normal limits. The tuberculin skin test shows an induration of 15 mm. The chest radiograph shows a healed fibrotic lesion in the upper lobe of the right lung. The HIV serology is negative. A T1W post-contrast axial MRI image reveals hypointense ring enhancing lesions in the left parietal lobe with significant perilesional edema but no hydrocephalous or midline shift. A lumbar puncture for cerebrospinal fluid (CSF) analysis is withheld in view of the significant perilesional edema on the imaging. What is the most rational next step in the management of the patient?
1. Start empirical 4-drug anti-tubercular therapy with steroids
2. Referral to neuroradiologist for stereotactic brain biopsy
3. Plan the surgical excision of the lesion
4. To do peripheral blood Interferon-Gamma release assay

A

1. Start empirical 4-drug anti-tubercular therapy with steroids

  • Diagnosis of tuberculoma is based on characteristic imaging of ring-enhancing lesions on contrast-enhanced CT scan or MRI of the brain.
  • When the diagnosis of tuberculoma is not possible with imaging or response to ATT is unsatisfactory, there is a progression of brain lesion, the definitive diagnosis can be made by stereotactic biopsy depending upon the availability of such a modality.
  • Brain tuberculomas are managed pharmacologically with first- line ATT and dexamethasone.
  • Surgery is indicated when tuberculoma >20 mm or if it is causing a mass effect in the form of midline shift or obstruction to CSF flow or when medical therapy fails.
50
Q

A 25-year-old man involved in a motor vehicle collision reports a loss of consciousness immediately following the collision and complains of difficulty hearing in his left ear. His pulse rate is 90 bpm, blood pressure 110/90 mmHg, and oxygen saturation 99% on room air. Glasgow Coma Scale score is E3V4M6, his pupils are bilaterally 2 mm in size and reacting to light, and there is mild bleeding from his left ear. There is no evidence of any other injury. A computed tomography scan of the brain shows a temporal bone fracture on the left side. Which of the following findings is most important to identify in the images of this patient?
1. Otic capsule involvement by the fracture
2. Mastoid process involvement by the fracture
3. Blood in the middle ear
4. Ossicular discontinuity

A

1. Otic capsule involvement by the fracture

  • The old classification of temporal bone fractures was based on whether the fracture was transverse or longitudinal to the petrous pyramid of the temporal bone.
  • Because many temporal bone fractures are complex and not easily categorized using the old classification, the new classification of whether the otic capsule (including the labyrinth and the cochlea) is involved is more useful.
  • Otic capsule involvement by trauma can lead to hearing loss, vertigo, and facial paralysis.
  • Damage to the ossicles can also lead to hearing loss, but this hearing loss would be considered conductive rather than sensorineural, which would more likely result from otic capsule involvement.
51
Q

A 14-year-old girl is brought to the emergency department after being hit by a fist to the right midfacial region. She reports hypesthesia of the right upper cheek and diplopia. Which of the following best describes the patient’s injury?
1. Nasal bone fracture with trigeminal nerve dysfunction
2. Zygomatic bone fracture with facial nerve dysfunction
3. Orbital floor fracture with trigeminal nerve dysfunction
4. Lateral orbital wall fracture with facial nerve dysfunction

A

3. Orbital floor fracture with trigeminal nerve dysfunction

  • The second branch of the trigeminal nerve runs through the maxillary bone forming the inferior portion of the orbit. Dysfunction may be the result of an orbital floor fracture.
  • Ocular motility disturbance results from incarcerated ocular muscles or surrounding fat tissue in bone fragments.
  • Vertical ocular motility disturbance, hypesthesia of the ipsilateral upper central incisor, and subcutaneous crepitus are all signs of this condition.
  • Facial nerve dysfunction is not common in midfacial trauma.
52
Q

A 1-year-old boy started with irritability, vomiting, and visual recognition problems for which the mother took him to the emergency department. He is found in acute distress. The emergency head computed tomographic scan showed hydrocephalus and a midline cerebellar mass. He is taken to the operating room after the brain magnetic resonance imaging was performed. The pathology report showed an embryonal tumor. Which technique will be used to classify embryonal tumors according to the 2016 central nervous system World Health Organization classification of central nervous system brain tumors?
1. Ki67 proliferation index
2. Electron microscopy of mitochondria
3. DNA methylation
4. Histochemistry

A

3. DNA methylation

  • DNA methylation profile is used to define the molecular/genetic diagnosis for the new 2016 classification of central nervous system tumors.
  • In 2016, the World Health Organization published a revised classification of central nervous system tumors using molecular parameters. Altered DNA methylation has been implicated in many tumors. Epigenetic alterations can explain the transformation of a normal cell to a cancerous cell. DNA methylation microarrays are used in studying the epigenetics of cancer.
  • Embryonal tumors are classified depending if they have on chromosome 19 an amplification of the C19MC region (19q13.42). If they have the amplification, they will be called embryonal tumor with multilayered rosettes, C19MC-altered (WHO 9478/3*). If they do not have the amplification, they are called embryonal tumor with multilayered rosettes, NOS (WHO 9478/3).
  • Histochemistry and Ki67 index are used in the histological analysis but will not provide genetic analysis. Electron microscopy shows the organelle structure of the cell but does not provide genetic characteristics.
53
Q

A 73-year-old male presents to the emergency department with altered mental status. The patient was found unconscious in the park and brought by EMS to the hospital. It is uncertain how long the patient has been unconscious. The patient’s medical history is unknown at this time. The patient does not have a wallet or forms of identification. On the physical exam, the patient is unable to follow commands, respond to painful stimuli, and reveal an ipsilateral dilated pupil. The heart rate is elevated and regular. Respirations reveal a diminished breath sound with no wheezing, rales, or rhonchi. The abdomen is soft, non-tender, and non- distended. There is no peripheral edema. The neuro exam reveals a bilateral Babinski sign. The cough and gag reflex is intact. Vitals are Temp: low-grade, HR: 80 bpm, BP: 145/100 mmHg, & RR: 29 bpm, O2 saturation: 99% on room air. CBC with differential, complete metabolic count, and procalcitonin are within normal limits. The drug and alcohol screen is negative. MRI imaging reveals complete obliteration of the suprasellar cistern, and the midbrain effaced and displaced inferiorly. What is the best course of management for this patient?
1. Dabigatran orally
2. Mechanical thrombectomy
3. Decompressive craniectomy
4. Low molecular weight heparin subcutaneously

A

3. Decompressive craniectomy

  • In patients with evidence of cerebral herniation, neurosurgery should be consulted, and decompressive craniectomy should be considered.
  • Complete obliteration of suprasellar cistern and midbrain that is both effaced and displaced inferiorly are signs of uncal herniation that require emergent decompressive craniectomy. Mechanical thrombectomy is not indicated because there is no evidence of large vessel occlusion due to a clot on imaging. For isolated cortical vein thrombosis, typically, the clot will present as an area of hypointensity within the cortical vein only on MRI.
  • Emergent decompressive craniectomy is the treatment of choice in the setting of cerebral herniation as confirmed by imaging. There is no evidence of large vessel occlusion to suggest that a mechanical thrombectomy will be beneficial.
  • Subcutaneous low molecular weight heparin is the treatment course for isolated cortical vein thrombosis, but it cannot treat uncal herniation. Anticoagulation treatment with dabigatran has no role in the management of uncal herniation.
54
Q

A 58-year-old man presents to the spine clinic with features suggestive of progressive neurological claudication. The bulk of his bilateral extensor digitorum brevis is wasted. He has weakness in his bilateral extensor hallusus longus. Electromyography of which of the following nerve is most helpful in the diagnosis of the patient?
1. L4
2. L5
3. S1
4. S2

A

2. L5

  • The patient has characteristic signs and symptoms of lumbar canal stenosis.
  • The weakness of extensor hallusus longus and bilateral wasting of extensor digitorum brevis suggest the prime involvement of the L5 nerve root.
  • The EMG of the L5 nerve root is very helpful in determining the degree and duration of the canal stenosis in the patient.
  • The involvement of L4 presents with weakened plantar flexion and diminished ankle reflex. The involvement of S1 presents with weakened flexor hallusus longus and diminished ankle reflex.
55
Q

A 74-year-old man has been diagnosed with metastatic deposits involving T12 and L1 vertebrae secondary to adenocarcinoma of the prostate. His MRI reveals grade 3 epidural spinal cord compression (ESCC). The lesion is highly radiosensitive. He is complaining of sudden onset, progressive bladder retention with perineal numbness of 5 hours’ duration. The rest of his sensory and motor components of neurological examination are normal. Which of the following is the most appropriate management strategy for this patient?
1. Intravenous dexamethasone
2. Immediate surgical spinal decompression
3. Immediate radiotherapy with conventional external beam radiation therapy (cEBRT)
4. Immediate radiotherapy with stereotactic radiation surgery (SRS)

A

2. Immediate surgical spinal decompression

  • Any patient with large metastatic vertebral deposits and significant spinal canal compromise presenting with progressive neurological deficit (conus medullaris syndrome, in this case), requires immediate spinal decompression surgery. This is a surgical emergency.
  • Duration and severity of neurological deficit are the most important prognostic indicators in such scenarios, and surgical decompression provides the quickest relief of compression of the spinal cord.
  • Such surgical decompression can be achieved by the posterior approach alone, a posterolateral approach involving 360° decompression of the spinal canal with or without anterior column reconstruction [with polymethyl methacrylate (PMMA) or cage reconstruction], anterior approach alone or combined anterior-and-posterior approach. With the recent advances in technology, all the surgical goals can be achieved with posterior or posterolateral approaches only.
  • Although steroids may have some role in ameliorating the neurological prognosis in cancer patients, there is no evidence supporting its role as the sole definitive treatment in these patients. Similarly, even in highly radiosensitive tumors with progressive neurological deficits, radiotherapy (cEBRT or SSRS) may not be the best approach to ensure immediate spinal canal decompression.
56
Q

A 72-year-old man presents with a four-month history of fatigue, weakness in his hands, and arm and leg pain. He also reports difficulty in swallowing. He denies any numbness or other sensory abnormalities. He has a past medical history of hypertension and hyperlipidemia and a 30 pack-year smoking history. All his vital signs are within normal limits. On examination, a coarse voice and sialorrhea are noted. There are marked fasciculations and atrophy of his arms, legs, and tongue, as well as hyperactive reflexes and bilateral Babinski sign. Given the most likely diagnosis, which of the following has been associated with a better survival rate?
1. Older age at onset
2. A lower functional rating scale score
3. Mild obesity
4. Bulbar symptoms

A

3. Mild obesity

  • The patient in the clinical scenario most likely presents with amyotrophic lateral sclerosis (ALS), which is a neurodegenerative disease of the motor neurons.
  • The diagnosis of ALS is made when there is upper and lower motor neuron degeneration, together with the clinical progression of signs and symptoms.
  • The median survival rate is 3 to 5 years; however, around 30% of patients survive five years from the diagnosis and only 10 to 20% survive for ten years.
  • Factors associated with a better survival rate include increased weight at diagnosis (mild obesity), younger age at onset, higher ALS functional rating scale score, forced vital capacity (FVC) at presentation, and limb rather than bulbar symptoms.
57
Q

A 37-year-old woman with a past medical history of migraines and polycystic ovarian syndrome is evaluated for a change in her usual headaches. The headaches are occurring more frequently and respond poorly to her previously effective medications. She is otherwise healthy and exercises three times per week. She wears contact lenses. She discontinued oral contraceptive pills eight years ago due to intolerance. She currently only uses ibuprofen and sumatriptan. On physical examination, her vital signs are normal. Her body mass index is 26 kg/mm2. The rest of her physical examination, including funduscopic examination, is normal. An initial CT brain was nondiagnostic. MRI with gadolinium reveals a 0.7 cm pituitary adenoma with a suprasellar extension but no compression or encroachment of the optic chiasm or optic nerves. There are no other abnormalities. Her chemistry panel is within normal limits. A urine pregnancy test is negative. Laboratory studies show: cortisol (8am) - 17 mcg/dL (normal: 5 - 25 mcg/dL), thyroid-stimulating hormone (TSH) - 3.6 mcU/mL (Normal: 0.5 - 5.0 mcU/mL), and thyroxine (T4) - 1.5 ng/dL (Normal: 0.9 - 2.4 ng/dL). Which of the following would be the best next course of action?
1. Visual field testing
2. Referral to neurosurgery
3. Measurements of prolactin and insulin-like growth factor 1 (IGF-1)
4. Abdominal CT scan to check for pancreatic masses

A

3. Measurements of prolactin and insulin-like growth factor 1 (IGF-1)

  • The establishment of a microadenoma versus a macroadenoma occurs with the size seen on an MRI, and the workup is dictated by this classification. All microadenomas require the complete pituitary hormonal panel to rule out hypersecretory tumors and must include insulin-like growth factor 1 (IGF-1) (for growth hormone) and prolactin levels.
  • On imaging or gross pathology, they can be classified according to their size as macroadenomas when greater than 1 centimeter or microadenoma when less than 1 centimeter.
  • Early morning cortisol levels are reserved for patients with symptomatic manifestations of Cushing’s syndrome.
  • Referral to a surgeon for transsphenoidal resection is required when adenomas are refractory to medical therapy, are specific secretory tumors, or cause visual field defects. Visual field testing is indicated in all tumors that are large in size, macroadenomas, or are abutting the optic chiasm or nerves on imaging. This microadenoma that the patient has no signs of abutting the optic chiasm. The patient also does not have any changes in her vision. Repeating an MRI and labs at 6 months is a reasonable option once a functioning pituitary tumor has been ruled out.
58
Q

A 30-year-old G1P0 female presents to her OBGYN for prenatal follow-up. She is currently 32 weeks gestation by eight-week ultrasound. Her pregnancy has mainly been uncomplicated, but she has been experiencing recurrent low back pain over the last six weeks. The pain is bilateral and is located across her deep in her posterior pelvis. She has been taking acetaminophen for her pain, but it only helps a little. The pain is stabbing in nature and has made it difficult for her to sleep on her back. She denies any numbness, tingling, or burning On exam; she is tender to palpation over the area between their gluteal folds and posterior iliac crests bilaterally. There is also pelvic asymmetry noted anteriorly. Her lower extremity range of motion, muscle strength, and sensation are intact bilaterally. The Patrick test elicits pain in her low back bilaterally. The patient is concerned that her back pain will not get better after delivery. What is the prognosis of this patient’s back pain?
1. Pain should resolve within the first two weeks following delivery.
2. It can take up to 12 months on average for her back pain to resolve.
3. Given the persistent nature of her pain, she is at risk for developing chronic low back pain.
4. Most cases improve after completing 12 sessions of physical therapy to help improve core muscle stabilization.

A

2. It can take up to 12 months on average for her back pain to resolve.

  • Pregnancy-related sacroiliac (SI) joint pain often resolves in the months following delivery. Sixty-two percent of women state their back pain has resolved three months postpartum.
  • SI joint injury is prevalent in pregnancy. Twenty percent of cases of SI joint injury are pregnancy-related. Eighty-six percent of women state their back pain is resolved 12 months postpartum.
  • Patients who experience pelvic girdle pain during pregnancy have high rates of disability than patients suffering mechanical back pain, but most cases resolve following delivery.
  • During pregnancy, laxity occurs within many of the joints in the pelvis. The hormone relaxin causes joint mobility during pregnancy. As the pelvis widens during pregnancy, the SI joint becomes more mobile. The expecting mother can experience SI joint pain as the hips rotate, putting stress on the SI joint. Over a period, the pelvis returns to its prior state.
59
Q

A 45-year-old man is brought to the hospital after a motor vehicle collision. He appears to have suffered a craniofacial injury and has raccoon eyes bilaterally. He is struggling to move his right eye medially. He also has loss of sensation on the medial aspects of his upper and lower eyelids and the bridge of his nose. Cranial nerves III, IV and VI are intact bilaterally. CT head shows a partial tear of his of one of his orbital muscles. Which of the following best identifies the injured?
1. Inferior aspect of the medial rectus
2. Superior aspect of the lateral rectus
3. Superior aspect of the superior oblique
4. Superior aspect of the medial rectus

A

4. Superior aspect of the medial rectus

  • The infratrochlear nerve runs anteriorly on the superior border of the medial rectus. It can be injured concominantly with injuries of the medial rectus.
  • The medial rectus is responsible for medial movement of the eyeball.
  • The medial rectus is innervated by oculomotor nerve (CN III).
  • The infratrochlear nerve receives a branch from the supratrochlear nerve (a branch of the frontal nerve) and moves through the medial aspect of the extraconal space of the orbit inferior to the trochlea. It exits the orbit under the superior orbital margin and above the medial canthal tendon.
60
Q

A 5-year-old male presents with headache, ataxia, and clumsiness for 4 weeks. Examination reveals dysmetria in the right hand along with truncal ataxia. An ocular exam reveals papilledema. There is no history of fever. MRI imaging reveals a large cystic lesion exhibiting mural enhancement measuring 5 cm in diameter. What is the most likely diagnosis?
1. Medulloblastoma
2. Pilocytic astrocytoma
3. Glioblastoma
4. Ependymoma

A

2. Pilocytic astrocytoma

  • This 5-year-old patient with symptoms of cerebellar pathology evident by dysmetria, ataxia, and an MRI revealed a cystic mass lesion in the cerebellum is most likely a case of pilocytic astrocytoma.
  • Brain tumors in children are most likely to be located in the infratentorial region and hence present with signs of cerebellar pathology.
  • Pilocytic astrocytoma is the most common tumor of childhood followed by medulloblastoma. The tumor typically consists of a cystic component that presents are hypodensity within the hyperdense tumor mass.
  • Glioblastoma is a tumor found in elderly patients and is poorly circumscribed and butterfly-shaped. Ependymoma is a periventricular solid mass lesion without any cystic component. Medulloblastoma is found in the infratentorial region but is a midline tumor and arises from the vermis and is unlikely to present with dysmetria. Instead, it would present with truncal ataxia.
61
Q

A 55-year-old patient presented to the emergency department (ED) following a fall from a two-storeyed building. The patient had the neurological status of the American spinal injury association (ASIA) ‘C’ following his neurological examination. The MRI spine revealed the presence of a Meyerding grade 3 subluxation of the cervical spine at the interface of the fifth and sixth cervical vertebral levels. Evidence of reduction in the subluxation despite the application of cervical traction was lacking. The treating clinician opts for the posterior fixation of the spine with lateral mass screw fixation. Trying to avoid the most feared complication of the procedure, the lateral is divided into four quadrants with horizontal and vertical imaginary lines. The point of insertion of the screw is just medial and below the point of intersection of the two lines. What is the lateral mass quadrant towards which the screw needs to be projected while inserting the screw so as to minimize the complications during the procedure?
1. Upper inner quadrant
2. Upper outer quadrant
3. Lower inner quadrant
4. Lower outer quadrant

A

2. Upper outer quadrant

  • The lateral mass screw fixation is a common surgical procedure applied during the posterior fixation of the cervical spine. However, there are risks of inadvertent injury to the vertebral artery and the exiting nerve roots during the procedure.
  • The lateral mass can be divided into four quadrants with a horizontal and verticle imaginary lines. The vertebral artery courses through the upper inner and the lower inner quadrants. The exiting nerve root lies underneath the lower outer quadrant.
  • The safest point of insertion of the lateral mass screw is just below and medial of the intersection of the two lines. The screw should then be inserted projecting towards the upper outer quadrant so as to safeguard form the injury to the vertebral artery and the exiting nerve root.
  • The insertion of the screw towards the medial quadrants of the lateral mass herald the risk of vertebral artery injury. The insertion of the screw towards the lower outer quadrant increases the risk of injury to the exiting nerve root.
62
Q

A 17-year-old male is brought to the office for headaches for three weeks. He has daily, dull pain in the frontal area of his head that is associated with nausea and vomiting. He has some episodes of blurred vision in the right eye. Vital signs are stable. Examination reveals bilateral optic disc swelling. Motor and sensory examinations are unremarkable. The MRI shows a lesion of the frontal lobe that is well defined, of low intensity and does not enhance. Which of the following is the most likely recommended treatment for this condition?
1. Chemotherapy
2. Radiotherapy
3. Third ventriculostomy or shunt placement
4. Surgery

A

4. Surgery

  • The patient has low-grade glioma (LGG) in the frontal lobe. In this age, LGGs are among the common brain cancers.
  • Nausea, vomiting, and headache are common presentations for a brain tumor due to compression effects. Surgery is the mainstay of treatment for LGG.
  • MRI shows well defined, low intensity, and no enhancement of the mass, and this is the description of low-grade glioma.
  • Surgery is recommended in LGGs. Radiotherapy should be given to any patient with progressive neurologic symptoms. Chemotherapy and radiotherapy can be given in the recurrence of the tumor or post-operatively if needed rather than adjunctively.
63
Q

A 7-year-old boy is brought to the hospital by his mother. She complains that he has been having excessive thirst and urination for the past three weeks. Previously she thought that it was because of the change of weather, but now it is becoming too frequent. Of note in clinical history is that he had had previous cranial radiation due to a malignant tumor. His urine dipstick is negative for glucose, his calcium is 2.3 mmol/l (2.15- 2.55 mmol/L), and potassium is 4 mmol/L (3.5-5.3 mmol/L). Serum sodium result is 148 mmol/L (135-145 mmol/L) and serum osmolality is 300 mosm/kg (285- 295 mosm/kg). Which of the following is the next best diagnostic step?
1. Growth hormone provocative testing with arginine and glucagon
2. Synacthen test
3. Insulin tolerance test
4. Water deprivation test

A

4. Water deprivation test

  • Given the clinical history and exclusion of other common causes of polyuria and polydipsia including normal calcium, potassium, and negative urine dipstick for glucose, the patient is likely to have antidiuretic hormone deficiency and diabetes insipidus.
  • The initial evaluation is the water deprivation test. ACTH stimulation test and triple bolus test are used for anterior pituitary function.
  • Irradiation may have affected growth hormone secretion, however, there is no complaint regarding short stature.
  • Pituitary pathology is a complication of childhood cranial irradiation.
64
Q

A 32-year-old female has been complaining of left-sided tinnitus for several months. There is no history of previous head trauma. There are no known past medical issues. The otolaryngologist does not find any anomaly in the ear but orders a magnetic resonance imaging scan of her brain. On a contrast- enhanced T1 weighted image, a region of enhancement in the left transverse sinus is identified, which also contains multiple flow voids. What is the next best step?
1. Digital subtraction angiography
2. Contrast-enhanced computed tomogram scan of the brain including the internal auditory canals
3. Computed tomography angiography
4. Reassurance

A

1. Digital subtraction angiography

  • The description in this question is consistent with the dural arteriovenous fistula. Chronic dural arteriovenous fistula (dAVF) typically thromboses and contains a network of vessels that can be seen as flow voids on magnetic resonance imaging (MRI). The transverse-sigmoid junction is a common site where dAVF is seen.
  • Digital subtraction angiography is necessary to definitively establish a diagnosis of dAVF.
  • Digital subtraction angiography is necessary for treatment planning to define the fistulous point, where treatment is targeted, as well as associated relevant anatomy.
  • Computed tomography angiography can often identify dural fistula but lacks the sensitivity, specificity, and ability for treatment planning as with catheter angiography.
65
Q

A 26-year-old male patient is brought to the emergency department by paramedics with facial injuries after involved in a high-speed motor vehicle collision. He is on a backboard, which has a cervical collar to stabilize his neck. He lost consciousness and has a GCS of 8. A primary survey is completed and immediately endotracheally intubated. On physical examination, he has large laceration over the forehead, which is bleeding. A scalp laceration and a 4 cm deep laceration over his right arm are present. A clear discharge is noted from the nose. Which of the following injuries requires require administration of antibiotics?
1. Significant bleeding from a large laceration over the forehead
2. Bleeding from the scalp
3. Bleeding from the arm laceration
4. Clear fluid from the nose

A

4. Clear fluid from the nose

  • Le Fort fractures may be associated with a cerebrospinal fluid (CSF) leak; Le Fort III fractures predispose the patient to CSF leak.
  • In patients with sinus fractures and suspected CSF leaks, IV antibiotics should be administered.
  • Controlling hemorrhage from the nose and oral cavity is also important and should be simultaneously performed by anterior packing. However, the control of epistaxis may be difficult. Immediate reduction of fracture should be performed if packing fails to control epistaxis.
  • Posterior nasal packing should be avoided because of the risk of skull base injuries.
66
Q

A 42-year-old man was diagnosed with acromegaly and recently underwent transsphenoidal resection of a pituitary adenoma. What is the next most accurate step to assess if the surgery was successful?
1. MRI pituitary immediately post op
2. IGF-1 level immediately post-surgery
3. GH level immediately post-surgery
4. GH level after OGTT 4 months after surgery

A

4. GH level after OGTT 4 months after surgery

  • To assess for remission for acromegaly after surgery, IGF-1 level should be done. The timing is important. Immediate post- surgery IGF-1 levels are elevated due to their long half-life and can take at least 3 months to normalize.
  • In addition to checking IGF-1 levels, one can check a GH level after 75 g of glucose being administered. Some argue that checking GH levels after a normal IGF-1 level may not add additional information; however, up to 30% of patients can have discordant results.
  • A normal IGF-1 level and GH suppressed to less than 1 ng/mL after OGTT is indicative of remission. These levels should be checked at least annually as relapse can occur many years after remission.
  • Even though repeat imaging should be done after surgery, it should be done a minimum of 3 months after the surgery as it can take that long for the sterile compressed sponge and fat packing to be resorbed and not affect image interpretation assessing for disease recurrence.
67
Q

A 45-year-old woman sustains a blow to the right side of her head in a motor vehicle accident. She had a brief loss of consciousness and headache. However, she has no deficits upon presentation to the hospital. A non-contrast CT scan of the head is done, and she is discharged home. Over the period of the next couple of weeks, she notices double vision, conjunctival injection, tearing, eye irritation, and a pulsating sensation of the left eye. Which of the following is the gold standard test to confirm the diagnosis in this patient?
1. Brain MRI with contrast
2. Cerebral angiogram
3. Optic nerve sheath ultrasound
4. Formal visual field assessment

A

2. Cerebral angiogram

  • The sign and symptoms in this patient are suggestive of a carotid-cavernous fistula.
  • A carotid-cavernous fistula (CCFs) is an abnormal shunt from the carotid artery to the cavernous sinus.
  • Trauma, such as basilar skull fractures, projectile or slash injuries, or iatrogenic injuries, accounts for 70% to 75% of all CCFs.
  • A cerebral angiogram is the gold standard test for diagnosing a CCF, which can show filling of the cavernous sinus through the fistula, drainage pattern of the fistula, and presence of reflux into cortical veins following an injection of CCA (common carotid artery), ECA, or ICA.
68
Q

A 22-year-old female patient presents to your clinic after an MRI was performed due to progressive ataxia. The MRI demonstrated a unilateral cerebellar lesion with a hyperintense tiger-stripe appearance on T2-weighted images. The patient has a history of numerous surgical interventions for lesions throughout the body, but she tells you these have all been diagnosed as “irregular growths” that are non-cancerous. Mutation in which gene is associated with the syndrome described in this case?
1. BRAF
2. FGFR
3. PTEN
4. BRCA1

A

3. PTEN

  • Dysplastic cerebellar gangliocytoma (Lhermitte-Duclos disease) is often seen in the background of PTEN hamartoma tumor syndrome (Cowden syndrome).
  • The tiger-stripe appearance of dysplastic cerebellar gangliocytoma is due to the expansion of the internal granular layer from cellular replacement with abnormal ganglion cells.
  • Dysplastic cerebellar gangliocytoma is a WHO grade 1 lesion based on the 2021 WHO brain tumor classification schema.
  • Mutation in BRAF is commonly seen in other neuronal brain tumors.
69
Q

A 66-year-old left-handed woman presents to the clinic complaining of a 1-year history of a high amplitude kinetic tremor that does not allow her to enjoy her usual activities, including gardening, painting, and interior home designing. She tried multiple medications in the past, including levetiracetam, topiramate, and clonazepam, among others with little alleviation of symptoms. She does not want to try botulinum toxin injections because she is phobic of needles. She would like to explore surgical options during this visit. Which of the following is the most common complication of surgery for the patient’s condition?
1. Autoimmune encephalitis
2. Ischemic stroke
3. Aseptic meningitis
4. Hemorrhagic stroke

A

4. Hemorrhagic stroke

  • Holmes tremor is characterized by resting or intention tremor of low frequency and high amplitude. It is extremely rare, and only a few hundred cases have been diagnosed since its discovery.
  • Pharmacological treatments include antiepileptics (levetiracetam, topiramate), dopamine agonists, anticholinergics (e.g.trihexyphenidyl), benzodiazepines, and botulinum toxin injections. Surgical options for refractory cases include thalamic stereotactic ablation, gamma-knife thalamotomy, and deep brain stimulation (DBS) in the thalamic ventralis intermedius nucleus and globus pallidus internus.
  • Surgical complications of thalamotomy include intracerebral hemorrhage, dystonia, and speech disturbance.
  • Surgical complications of DBS include intracerebral hemorrhage and foreign body implant infections.
70
Q

A 45-year-old male inmate is brought to the emergency department after a physical altercation with his cellmate. Physical examination reveals bony depression of the left maxilla but is otherwise unremarkable. CT of the maxillofacial bones confirms the suspicion. The patient is taken to the operating room for open reduction with internal fixation of the left anterior maxillary sinus wall. During surgery, there is profuse bleeding just after entering the left maxillary sinus. Bleeding does not stop with packing and electrocautery. Which of the following arteries is most appropriate to be ligated to stop the bleeding?
1. Left internal carotid artery
2. Left ophthalmic artery
3. Left facial artery
4. Left maxillary artery

A

4. Left maxillary artery

  • This patient is undergoing open reduction internal fixation (ORIF) of the left anterior maxillary sinus.
  • The blood supply to the maxillary sinus comes from branches of the maxillary artery: posterior superior alveolar artery, infraorbital artery, and the posterior lateral nasal artery.
  • The first step to controlling bleeding in the OR is generally packing and electrocautery. If this does not work, the next best step is ligation or embolization of the arteries supplying the surgical field.
  • The maxillary artery is a branch of the external carotid artery.
71
Q

A 65-year-old patient presents with progressive pain and weakness in his bilateral lower limbs even while standing. The pain is relieved when he bends forward. He is vitally stable. He is not sexually active. He is a retired construction worker. He has a 30-pack-year smoking history. Past history is significant for unstable angina, hyperlipidemia, and hypertension. Medications include aspirin, metoprolol, atorvastatin, and lisinopril. Family history is significant for osteoporosis in the mother and knee dislocation in the father. His neurological examination reveals a positive stoop test and a significantly prolonged time for completing four repetitive sit-to- stand tests. His ankle reflex is diminished. Vascular examination of the lower extremities shows mildly decreased dorsal pedis pulses. The skin examination of the lower extremities is normal. MRI of the lumbar spine revealed multiple disc desiccations in the lumbar region. Which of the following is the index pathological event responsible for the patient’s condition?
1. Atherosclerosis of tibial arteries
2. Ligamental hypertrophy
3. Disc protrusion
4. Facetal instability

A

4. Facetal instability

  • The patient has a typical presentation of lumbar canal stenosis with neurological claudication. Spinal stenosis is a condition in which the nerve roots are compressed by a number of pathologic factors, leading to symptoms such as pain, numbness, and weakness.
  • The most recent theory suggests the facetal instability to be the pivotal point governing the pathogenesis of the lumbar canal stenosis. The facetal instability leads to compromised motion dynamics; therefore, the body compensates for the same with secondary compensatory mechanisms such as facetal hypertrophy, ligamental hypertrophy, and osteophytes formation. This leads to canal stenosis and, thereby, neurological claudication.
  • Risk factors are multifactorial. A detailed history of symptoms and physical exam is the initial evaluation of a patient with spinal stenosis. Diagnosis can be made through imaging with extended-release x-ray, CT, and MRI. Canal diameter reduced by less than 10 mm with a positive ‘sedimentation sign’ of the rootlets is a characteristic MRI finding.
  • Ligamental hypertrophy, osteophytes formation, and disc protrusion are now considered the compensatory chances following the facetal instability that compromise the supportive dynamics of the spine. Atherosclerosis of tibial arteries is seen in peripheral vascular disease.
72
Q

A 67-year-old male patient presents with bilateral tinnitus for over a year. He also has bilateral hearing loss. He is diabetic and hypertensive and lives alone. Examination of the ear reveals a right middle ear red mass that blanches with a positive pressure during pneumatic otoscopy. On the left retro auricular area, a noticeable bruit can be heard. Magnetic resonance imaging of the brain reveals bilateral tumors, the right measures 2.7 cm and the left 1.3 cm at the jugular foramen. Both have marked enhancement, and have the classic salt and pepper appearance. What is the best treatment for this patient?
1. Observation
2. Bilateral surgical resection
3. Radiation alone
4. Embolization

A

3. Radiation alone

  • Radiation alone can be utilized in the setting of bilateral glomus jugulare tumors and can represent an adjunct to limited surgical approaches with associated subtotal resection.
  • Radiation modalities include standard fractionated radiotherapy and stereotactic radiosurgery. Standard fractionated radiotherapy requires multiple sessions while radiosurgery can be given in a single session providing focused radiation and, at the same time, sparring the vulnerable surrounding tympanic bone.
  • The middle ear examination will reveal a red mass that blanches with a positive pressure during pneumatic otoscopy.
  • Observation provides an excellent treatment alternative, as 65% of tumors remained stable or even regressed in size. Approximately 40% of tumors demonstrated growth at an average of 0.9 mm per year.
73
Q

A 65-year-old man with a history of osteoarthritis of his knees and type 2 diabetes presents to the office with a 1-week history of sudden but gradually worsening low back pain. The pain is described as burning and stinging in nature, radiating down his right posterior thigh. The patient states his pain constant and nothing makes it better or worse. He denies any recent trauma or illness, denies any numbness or tingling and denies any bowel or bladder incontinence. On physical exam, there is no point tenderness over her lower lumbar spine. Hip flexion, knee flexion, knee extension, plantar flexion, dorsiflexion muscle strength is 5/5 bilaterally. Lower extremity sensation is intact bilaterally and deep tendon reflexes for the L4, S1 are 2/4 bilaterally. A straight leg raise elicits pain on the right. FABER test is negative bilaterally. Hypertonicity of the paraspinal muscles is not appreciated on the exam. What is the most likely prognosis of the patient’s condition?
1. It should improve with bed rest over the next one to two weeks
2. It will likely resolve over the course of six weeks
3. He will likely have a long, six-month recovery but will improve with physical therapy
4. He will likely not improve with conservative management and will require surgical intervention

A

2. It will likely resolve over the course of six weeks

  • Most cases of lumbosacral radiculopathy are self-limited. Counseling is essential for patients with radicular symptoms since most cases are mild and will resolve within six weeks after the onset of symptoms.
  • Lumbosacral radiculopathy is very common. On average, 3 to 5% of adults will experience symptoms in their lifetime. Spontaneous improvement following a disc herniation or lumbar spinal stenosis is very high.
  • There are three categories of radicular symptoms and signs; mild, moderate, and severe. This is a case of mild radiculopathy. It is considered in a patient experiencing a sensory loss and pain without motor deficits. This has the best prognosis and most likely to spontaneously recover.
  • Bed rest has not been shown to effective in the treatment of lumbar radicular pain, and results of physical therapy have been shown to be inconclusive. Given mild symptoms patient will likely recover and not require surgery.
74
Q

A 65-year-old man is brought to the emergency department (ED) after sustaining a head injury secondary to involvement in a motor vehicle collision. In the ED, he is obtunded with a Glasgow coma scale (GCS) score of 9. He vomits during the primary survey evaluation. His vital signs are as follows; temperature 99.8 degrees Fahrenheit, heart rate 110 beats per minute, respiratory rate 14 breaths/minute, and blood pressure 96/44 mmHg. He has unequal pupils, and the right pupil is dilated and not reactive to light. The ED team using rapid sequence induction, immediately intubates him. A non-contrast CT scan of his brain shows a large right epidural hematoma with a midline shift. His pelvic x-ray shows a fracture of the right femur shaft with displacement. What should be the priority in his evaluation and further management?
1. Arrange emergency evacuation of the epidural hematoma
2. Arrange immediate reduction and internal fixation of the femur fracture
3. Arrange for transfusion of packed red blood cells
4. Arrange a transfer to a trauma center

A

1. Arrange emergency evacuation of the epidural hematoma

  • Evaluation of airway, breathing, and circulation should precede the neurological evaluation, and their stabilization should be the priority. Another priority is to optimize perfusion and oxygenation to prevent hypoxia and hypotension.
  • Patients with epidural hematoma (EDH) should receive operative intervention; this includes craniotomy followed by evacuation of hematoma and cessation of intracranial bleeding. In general, patients with EDH greater than 30 mL in volume should receive surgical intervention regardless of the GCS score.
  • The presence of EDH is a true neurosurgical emergency; the time between neurologic deterioration and surgical intervention greatly influences the outcome.
  • After initial stabilization, an immediate CT scan of the brain should be obtained in order to decide whether prompt operative treatment is required. The patient must be stabilized prior to transfer to another facility.
75
Q

A 23-year-old female is brought in to the hospital after being involved in a motor vehicle collision. She reports a minor headache but no other aches or symptoms. On physical exam, she has normal vital signs. Her BMI is 20 kg/m2. She has a small bruise over her right temple region but no other bruises, scrapes, or cuts anywhere over her body. Her initial labs are within normal limits. CT brain does not show any bleeding; however, it does reveal a pituitary mass. This is confirmed with an MRI and is found to be of 1.1 cm with suprasellar extension towards the optic chiasm but not compressing the chiasm or the nerves. She has further evaluation with a visual field test that shows preserved vision in all directions. Further laboratory testing is as follows: prolactin 19 ng/mL (normal: 20 in women), thyroid-stimulating hormone (TSH) 2.2 mcu/L (normal: 0.5-5.0 mcu/L), free thyroxine (FT4) 1.2 (normal: 0.8-1.8 ng/dL), insulin-like growth factor 1 (IGF-1) 460 ng/mL (normal for age: 113- 297 ng/mL), luteinizing hormone (LH) 30 IU/L (normal: 20-80 IU/L for midcycle, female), follicle-stimulating hormone (FSH) 18 mcu/L (normal: 4-36 mcu/mL for midcycle, female). A glucose tolerance test confirms the high likelihood of the tumor being a somatotrophic pituitary macroadenoma. Which of the following is the best next step?
1. Proceed with stereotactic radiosurgery (SRS) and observe for symptoms
2. Transsphenoidal biopsy of the mass for staging and grading of the pituitary tumor
3. Prescribe a somatostatin analog and repeat MRI imaging in 1 year
4. Transsphenoidal resection of mass followed by octreotide administration

A

4. Transsphenoidal resection of mass followed by octreotide administration

  • There are several treatment options for treating pituitary tumors. Tumors are classified as micro- or macroadenomas and need to have laboratory testing to determine if these are hypo or hypersecretory masses. 0.2% of pituitary masses are malignant carcinomas, and therefore no staging or grading system exists.
  • Somatotrophic macroadenomas are adenomas with an excess of growth hormone production. Insulin-like growth factor 1 (IGF- 1) elevation is very common and routinely tested early in the workup of a pituitary tumor and is followed by a growth hormone (GH) suppression test. All growth hormone-producing tumors, regardless of symptoms, require transsphenoidal surgical resection as first-line therapy. Somatostatin analogs, such as octreotide, are then used to suppress remaining tumor tissue, and can often require repeat surgery to remove 100% of the adenoma.
  • Macroadenomas that are found to be nonsecretory and do not cause and vision loss need to be followed with an MRI after 6 months of diagnosis. An increase in size or growth towards the optic nerves and chiasm should prompt consultation for surgical resection. Secretory adenomas almost always require medical, surgical, radiological, or a combination of them all at the time of diagnosis.
  • Stereotactic radiosurgery (SRS) is a form of radiological treatment with gamma rays. Radiological therapy is never done alone and only augments medical or surgical therapy.
76
Q

A 38-year-old woman presents complaining of pain in her lower back for more than three months. A cystic, expansile L3 vertebral body lesion is seen on plain roentgenogram, and encroachment onto the spinal canal is detected on MRI. Detailed evaluation reveals an aggressive spinal high RANKL expressing mass. What is the most appropriate management strategy for this patient?
1. Complete excision and radiotherapy
2. Curettage, radiotherapy, and zoledronate
3. Insertion of polymethylmethacrylate (PMMA), radiotherapy, and belimumab
4. Radiotherapy, transcatheter embolization, pamidronate, and denosumab

A

4. Radiotherapy, transcatheter embolization, pamidronate, and denosumab

  • Aggressive spinal giant cell tumors (CTGs) are considered to be unresectable.
  • Radiotherapy is recommended for the spinal, sacral, or aggressive tumors when complete excision or curettage is impractical for any functional or medical reasons.
  • A trans-catheter embolization of the blood supply can be used for the unresectable GCTs (e.g., specific pelvic or sacral tumors).
  • Reports show that topical or systemic bisphosphonates like zoledronate or pamidronate can be used as a novel adjuvant therapy for GCT. Bisphosphonates induce apoptosis and limit the tumor progression by targeting the osteoclast-like giant cells
77
Q

An 81-year-old man presents six months following hernia repair with intractable groin pain. He has been started on appropriate pharmacological, topical, and lifestyle modification without resolution of symptoms, and interventional management with cryoablation is chosen as the next step. Which of the following sets of nerves is most appropriate to be targeted in this patient?
1. Pudendal, ilioinguinal, hypogastric
2. Ilioinguinal and genitofemoral
3. Genitofemoral and iliohypogastric
4. Ilioinguinal, iliohypogastric, and genitofemoral

A

4. Ilioinguinal, iliohypogastric, and genitofemoral

  • The patient likely has chronic post-herniorrhaphy pain. Ilioinguinal and iliohypogastric cryoablation would be appropriate in this setting with or without the addition of genitofemoral. Pudendal nerve block would not be chosen in this setting.
  • The ilioinguinal nerve is smaller and courses caudad to the iliohypogastric nerve, both nerves course between the internal oblique and the transverse abdominis muscle.
  • When blocking or ablating the iliohypogastric and ilioinguinal nerves, a proximal target should be chosen prior to the nerve branching (close to where the nerves transverse the muscles near the iliac crest).
  • The injection of a small amount of fluid to hydro dissect the correct plane can assist with localization and reduce the chances of intramuscular injection/ablation.
78
Q

A 65-year-old male had a long-standing history of chronic pain. Three months ago, he underwent spinal laminectomy for lumbar spinal stenosis secondary to degenerative changes. He presented again with lower back pain. Which of the following treatment options will be most appropriate for this patient?
1. Spinal cord stimulator
2. Opioids
3. Reoperation
4. Epidural steroid injections

A

1. Spinal cord stimulator

  • Spinal cord stimulator implantation has been shown in studies to be effective for failed back surgery syndrome (FBSS). This has been reported in large randomized trials.
  • Opioids and reoperation have been shown to be ineffective in FBSS treatment but are still commonly used.
  • Epidural steroid injections have been shown in some studies to be of benefit, but these studies are generally of weaker quality.
  • Repetitive use of opioids remains subpar as efficacy decreases chronically. Only spinal cord stimulator implants have been shown to mitigate low back pain from FBSS.
79
Q

A 43-year-old man presents to the clinic with a complaint of pain in the neck along with a tingling sensation in the right upper forearm after a history of fall from a height. The radiograph reveals fused vertebrae and a radiolucent line in the C5 vertebra. An initial set of labs is significant only for HLA-B27 positivity. What is the most appropriate management strategy for this patient?
1. Posterior decompression and C4-C6 fusion
2. Posterior decompression and C3 -C7 fusion
3. Anterior decompression and C3-C7 fusion
4. Halo immobilization

A

2. Posterior decompression and C3 -C7 fusion

  • The above vignette reveals a C5 fracture in an ankylosed spine.
  • Posterior decompression and instrumentation are indicated in this patient.
  • The posterior approach is easy and has the benefit of using long lever arm instrumentation.
  • Long lever-arm of instrumentation is preferred, which is not possible in the anterior approach.
80
Q

A 46-year-old woman visited the hospital with symptoms of nasal obstruction, sudden involuntary movement of the body, and one-sided headache. She has a history of type-2 diabetes for 13 yrs on medication. Laboratory findings showed WBCs and eosinophils within normal limits, serum glucose level 118mg/dl and HbA1c 6.5%. Endoscopic examination revealed a black necrotic mass, discharge mixed with blood, and bony erosion. What is the most likely pathogenesis of this disease?
1. Hematogenous spread
2. Vascular endothelial invasion
3. Invasion and spread through neuron axonal transport
4. Lymphatic spread to the central nervous system.

A

2. Vascular endothelial invasion

  • Humid nasal cavity and sinuses make initial implantation favorable for fungal spores.
  • Necrosed tissue is the nidus for the growth and spread of fungi.
  • Invasion and erosion of bone lead to bone destruction that creates a direct path of transmission of fungi.
  • Rapid progression of rhinocerebral mucormycosis is due to vascular endothelial invasion and thrombosis, which leads to ischemia and tissue necrosis.
81
Q

A 25-year-old woman with a BMI of 35 kg/m2 undergoes an abdominal wall lipoma excision under spinal anesthesia. Postoperatively, she has severe headaches, especially on standing up. She subsequently undergoes an epidural blood patch for the management of her problem. Which of the following best describes the chances of the patient’s symptoms improving on the first attempt with this treatment?
1. 50%
2. Less than 33%
3. More than 90%
4. 75% to 80%

A

4. 75% to 80%

  • Epidural blood patches (EBPs) will likely resolve post-dural puncture headache (PDPH).
  • Most of PDPH’s resolve spontaneously within 7 to 10 days.
  • There is a greater than 90% success rate with a second EBP if the first fails.
  • Typically 75% to 80% of PDPH’s resolve rapidly with an EBP.
82
Q

A 16-year-old patient with severe traumatic brain injury is found to have brain stem areflexia. The apnea test was not possible due to his hemodynamic instability. The treating clinician opted to perform a cold caloric reflex test on the left ear. What is the pattern of eye response seen following the caloric reflex test in the patient with brain stem death?
1. Conjugate deviation to the left
2. Conjugate deviation to the right
3. No movement of the eyes
4. Dysconjugate movement of the eyes

A

3. No movement of the eyes

  • The caloric reflex test is a component of an electronystagmography used to assess the patency of the vestibulo-ocular reflex.
  • The vestibulo-ocular test in a brain stem death will not show any conjugate movement of the eyeballs.
  • Normally, ice-cold water will suppress the firing of vestibular firing, thereby simulating head turn to the opposite side, resulting in the ipsilateral conjugate deviation of the eyes.
  • On the other hand, the warm water increases the vestibular firing and results in the contralateral conjugate deviation of the eyes.
83
Q

A 12-year-old patient presents to the emergency room with progressively worsening headaches, nausea, and vomiting for the past two weeks. The patient is alert and oriented. Neurological examination revealed upward gaze paresis. Fundoscopy revealed bilateral papilloedema. MRI brain imaging showed obstructive hydrocephalus secondary to a homogeneously enhancing mass in the pineal region. Which of the following is the patient’s most rational initial management strategy?
1. Radiotherapy
2. VP shunting
3. Gross microsurgical excision
4. Endoscopic procedures

A

4. Endoscopic procedures

  • Endoscopic third ventriculostomy is the most rational surgical strategy in the patient.
  • This allows for the histological confirmation of the lesion as well as CSF analysis for the tumor markers for proper stratification.
  • ETV also obviates the need for permanent shunt procedures in most cases of obstructive hydrocephalus.
  • Gross microsurgical resection may be obviated in selected few cases of pineal region tumors through radiation. VP shunting has many short and long-term complications such as infections and obstructions.
84
Q

A 70-year-old patient with a history of chronic hypertension and cardiovascular disease presents to the emergency department with complaints of sudden-onset dysphagia, hoarseness, and nystagmus. Apart from a blood pressure of 160/95 mmHg, his vital signs are unremarkable. On physical examination, he has decreased sensation to pinprick on the left side of his face and right side of his body. He has a diminished gag reflex, and it is noted that his uvula points to the right. No weakness or loss of sensation is noted. No facial droop is present — no deficits in vision or extraocular movements. A stroke in the brainstem is suspected. What is the most likely part of the brainstem that is affected in this lesion?
1. Lateral pons
2. Medial pons
3. Lateral medulla
4. Medial medulla

A

3. Lateral medulla

  • Lateral medullary syndrome (also known as Wallenberg syndrome) is a constellation of symptoms that occur due to a lesion or infarct in the lateral part of the medulla.
  • The lateral medulla includes the nucleus ambiguus, which primarily innervates the motor branches of cranial nerves IX and X.
  • Damage to the nucleus ambiguus causes dysphagia, hoarseness, and absent/reduced gag reflex.
  • Median medullary syndrome classically involves CN XII. Lateral pontine syndrome involves cranial nerve VII and causes ipsilateral Bell’s palsy. Median pontine syndrome affects CN VI, which causes the ipsilateral eye to look down and towards the nose.
85
Q

A 17-year-old male patient presents with headaches and fever for the past week. He has no know medical comorbidities. The physical examination shows no cranial nerve, motor, or sensory deficits. He has positive nuchal rigidity and no Babinski. Cerebrospinal fluid (CSF) examination results reveal: WBC 5000 cells/mm^3, 90% PMNs, glucose 25 mg/dL, protein 290 mg/dL, and gram-positive diplococci on gram stain. Which of the following treatments should be started?
1. Ceftriaxone and vancomycin
2. Tazobactam and vancomycin
3. Ceftriaxone and gentamicin
4. Cefepime and gentamicin

A

1. Ceftriaxone and vancomycin

  • Bacterial meningitis is caused by a bacterial infection of the meninges, resulting in inflammation.
  • Bacterial meningitis causes the following CSF profile: elevated opening pressure of 200-300 mmH2O, WBC >1000 cells/mm^3 with more than 80% PMNs, glucose 40 mg/dL, and protein >150 mg/dL.
  • Empiric treatment with ceftriaxone and vancomycin should strongly be considered if the diagnosis is going to be delayed.
  • Patients who are immunocompromised or older than 50 should also receive ampicillin.
86
Q

A 25-year-old man is being evaluated in the hospital a machete attack. He has already spent a few days in hospital dealing with his other injuries, which took precedent. He has a 3 cm defect on his scalp. The patient is complaining that the wound feels wet all the time. Which of the following is the next best step in the management of this patient?
1. Intravenous vancomycin
2. Allow it to heal by secondary intention
3. Rotational flap to close the defect
4. CT head

A

4. CT head

  • Often in polytrauma cases, multiple specialties are involved, and the more obvious serious injuries take precedent. Any head injury is normally picked up in the primary or secondary survey. This appears to be a small scalp defect, and the seriousness of it may not have been appreciated initially.
  • A wound infection can be wet. But in this case, it is important to establish if the discharge is clear as a traumatic cerebrospinal fluid (CSF) leak is the concern.
  • The most important action is to order a CT head scan, or review one if previously done on admission, to view the bony windows in detail for a bony fracture or breach in the skull. The fluid can also be collected and sent off for beta-2-transferrin to confirm if it is CSF.
  • If a fracture with a CSF leak is found, surgical management of the CSF leak would take priority.
87
Q

A 16-year-old male patient is brought to the emergency room with a history of one episode of focal seizures involving the left side of the face and left upper limb, which lasted for 2 minutes. He did not lose consciousness at that time, and this is the first time he is having seizures. He does not have any similar family history. On examination, he does not have any neurological deficits. A magnetic resonance imaging scan of the brain is done, which shows a T1and T2 mixed signal intensity lesion near the right motor cortex with low signal rim blooming on T2* sequences. Why is this lesion prone to produce seizures in this patient?
1. Iron pigments
2. Presence of infection
3. Lack of oxygen
4. Elevated levels of pCO2

A

1. Iron pigments

  • The patient is having a cavernous angioma of the brain. Also because of their propensity to act as an epileptogenic focus CMs should always be considered in the workup of a patient with a seizure disorder, especially if the patient is aged 20-40 years.
  • The lesions also may vary in consistency from soft to hard depending on the degree of calcification and thrombosis.
  • The increased leakage of iron from hemoglobin is one reason that explains the high prevalence of seizures in patients who have cavernous angiomas.
  • The adjacent brain tissues appear gliotic and are usually yellow due to the leaked hemosiderin.
88
Q

A 65-year-old male patient sustained a C1 burst fracture following a motor vehicle accident (MVA). The injury was managed conservatively by the use of a hard cervical collar. The patient was on regular follow-up throughout his fracture treatment, and he was significantly improving with rest concerning pain and activity status since the time of injury. It has been three months since the time of his injury. He wishes to know if he can be weaned off his cervical collar at this point. What is the next most appropriate step?
1. Reassurance and discontinuation of the collar.
2. MRI cervical spine to rule out transverse atlantal ligament (TAL) injury.
3. Conversion of the collar to halo vest, as these fractures are notorious for complications.
4. Cervical dynamic (flexion-extension) imaging.

A

4. Cervical dynamic (flexion-extension) imaging.

  • The treatment of atlas fractures remains controversial, in part due to frequent occurrence of other cervical injuries in association such injuries.
  • Non-operative treatment consists of external orthoses or bracing and is often effective if the fracture is stable. This includes a hard cervical collar, halo vest, cervical traction, and Minerva jacket.
  • Before discontinuing the orthosis in these patients, dynamic cervical imaging is of utmost importance to rule out any chronic C1-C2 instability secondary to transverse atlantal ligament rupture.
  • The patients with instability at C1-C2 (dynamic cervical imaging) greater than 5 mm (at three months) need surgical C1-2 fusion, to ensure that there is no delayed worsening of displacement or neurological deficits.
89
Q

A 65-year-old woman complains of headaches and vertigo. Gradually, the patient develops spastic hemiplegia on the left side, with hyperactive deep tendon reflexes of the left arm and leg. The patient complains of double vision. The examination reveals that her right lateral gaze is normal. But when she is asked to look to the left side, the right eye fails to adduct, and the left eye has nystagmus on abduction. Pupillary reactions are normal. Where is the lesion most probably located?
1. Medulla oblongata
2. Cerebellum
3. Pons
4. Mesencephalon

A

3. Pons

  • The patient exhibits a syndrome called internuclear ophthalmoplegia (INO) which is due to a lesion in the medial longitudinal fasciculus (MLF).
  • MLF is a heavily-myelinated tract in the pons that allows conjugate eye movement by connecting the paramedian pontine reticular formation (PPRF), the abducens nucleus complex of the contralateral side to the oculomotor nucleus of the ipsilateral side.
  • In young patients, INO is most likely due to multiple sclerosis. In the elderly, it is more commonly caused by a brainstem stroke.
  • Bilateral INO is almost pathognomonic of a demyelinating disease such as multiple sclerosis.
90
Q

Idiopathic normal pressure hydrocephalus (iNPH) is a cause of dementia in the elderly population. Its incidence significantly increases after 80 years of age. Select the least accurate statement from the following options
1. The classic triad of symptoms consists of urinary incontinence, cognitive decline, and gait disturbances
2. 0.1% of the population above 80 develop this condition
3. The lumbar tap test has a high positive predictive value in determining if a lumboperitoneal shunt will improve symptoms
4. The longer that iNPH has existed, the less likely that a shunt will result in complete resolution of symptoms

A

2. 0.1% of the population above 80 develop this condition

  • The prevalence of probable iNPH is 0.2%-0.5% in those aged 70–79 years and increases beyond 5%-7% after 80 years of age.
  • The lumbar tap test is performed to obtain cerebrospinal fluid pressure, obtain a sample for analysis (normal in iNPH) and a large (30-40 ml) drainage to see if there is any improvement of symptoms to aid diagnosis and prognosis. A negative response does not necessarily indicate that a patient will not improve with shunting but reduces the chances of clinical success.
  • Additional testing includes external lumbar drainage for several days and radionuclide cisternogram in which a radioactive agent is injected and serial radiographic studies assess time to clear which is delayed in iNPH.
  • Surgeries involve ventriculoperitoneal shunt and lumboperitoneal shunt.
91
Q

A 3-month-old boy is brought to the clinic for evaluation of an abnormal head shape. On evaluation, the patient has severe frontal bossing with an elongated “boat-shaped” head. Imaging findings describe premature closure of sagittal suture. What is the most appropriate management strategy for this patient?
1. Personalized skull-molding helmet
2. Endoscopic cranial vault remodeling
3. Open cranial vault remodeling
4. Observation

A

2. Endoscopic cranial vault remodeling

  • The patient has sagittal craniosynostosis with severe deformity features that have a surgical indication for which surgical treatment is the best option for this patient.
  • There are different types of surgical techniques for treating craniosynostosis. In this patient with 3 months of age in an experienced facility, endoscopic surgery is the best option since it decreases associated blood loss in comparison to open surgery. The addition of helmets post-operative has been associated with better outcomes.
  • More than for any other suture, endoscopic treatment of sagittal synostosis has proved to be very effective and is becoming the treatment of choice at many institutions.
  • Skull molding helmets are an option when the deformity is not severe, especially in patients where the deformity is not associated with craniosynostosis (ie. positional plagiocephaly). Observation is an option in patients with mild/subtle deformities without any associated signs/symptoms (ie. increased ICP)
92
Q

An 18-year-old male patient was observed in the emergency room department after a rock-climbing accident. On admission, his vitals were stable and normal, but the physical examination was significant for motor paresis and hyper-reflexes of his arms bilaterally. Primary touch deficits were also observed bilaterally for his feet and legs. Based on the history and physical examination, what is the most likely anatomical location of his lesion?
1. Cauda equina
2. Central cord
3. Anterior half of the cord
4. Posterior half of the cord

A

2. Central cord

  • Upper motor neuron signs cause hyperreflexia, paresis, and sometimes paralysis. Upper motor neuron lesions can occur anywhere between the cortex and the spinal cord. In contrast, lower motor neuron deficits cause hyporeflexia.
  • Central cord syndrome is caused by damage to the central regions of the spinal cord. It is commonly elicited by hyperextension of the cord at the cervical level.
  • Central cord syndrome causes damage to the dorsal column tracts (i.e., fasciculus gracilis and cuneatus). Fasciculus gracilis has axons that represent the lower body, while fasciculus cuneatus has axons that carry touch information for the upper body. Because fasciculus gracilis is located medially, it has more axons within the central portion of the spinal cord. Therefore, patients with central cord syndrome will typically have deficits with touch sensation more in the lower body than the upper body.
  • Central cord syndrome causes damage to the lateral corticospinal tract. The lateral corticospinal tract homunculus has feet represented peripherally and the upper body represented centrally within the cord. Therefore, central cord syndrome would show upper body motor impairment more than lower body impairments.
93
Q

A 16-year-old patient undergoes external ventricular drain (EVD) placement for acute hydrocephalus secondary to tubercular meningitis. One week later, he is prepared for ventricular shunt placement. On the morning of the day of surgery, the EVD is electively clamped. The surgeon makes multiple attempts to tap the ventricle during ventriculostomy, but no egress of cerebral spinal fluid is observed. What is the most likely cause for this dry tap during ventriculostomy?
1. Intraventricular hemorrhage
2. Pneumoventriculi
3. Wrong trajectory
4. Collapsed ventricle

A

2. Pneumoventriculi

  • Pneumoventriculi is a common cause of dry tap during ventriculostomy.
  • A breach in the air-locked system of the ventricular drainage bag causes a high incidence of air in the ventricular system. This can lead to a dry tap during ventriculostomy.
  • Other probable causes include head-up positioning of the patient during ventriculostomy. The inadequate cruciate incision at the dura can lead to subdural pneumocephalus, thereby altering the position of the ventricles due to the resultant brain shift.
  • The possibility of a collapsed ventricle is minimal because the external ventricular drain is also clamped for hours before ventricular-peritoneal shunting. Wrong trajectories, despite multiple attempts from an experienced surgeon, are a rare occurrence.
94
Q

A 38-year-old female presents with a six-month history of low back pain, which started following the vaginal delivery of her child. She is considering having another child but is worried she cannot manage this pain. Her past medical history is significant for seasonal allergies and generalized anxiety disorder. The pain was initially sharp and made worse with movement and has become worse over the past three months. The patient complains of constant pain in her lower lumbar region and her knees, elbows, and neck. The pain is dull and achy, but sometimes it is made worse by cold weather. She often complains of fatigue and difficulty sleeping. She denies any loss of muscle strength or changes in sensation. She denies any bowel or bladder incontinence. Nothing seems to make it better, but she is worried her pain will only continue to get worse. Her physical exam is primarily unremarkable except for moderate tenderness to palpation of her right sacroiliac joint. She also reports pain to light palpation of her elbows, neck, and knees. What is the best initial step in the management of this patient?
1. Magnetic resonance imaging (MRI) lumbar spine
2. Referral for physical therapy
3. Cognitive-behavioral therapy
4. Start on duloxetine

A

2. Referral for physical therapy

  • The patient is experiencing the phenomenon of central sensitization following traumatic acute back pain, which has become chronic. The initial management for this patient would be first to correct the underlying back pain.
  • Given this patient’s pain is likely due to birth trauma, if the patient’s mechanical back pain can be corrected, her discomfort may resolve completely.
  • The patient’s acute pain became chronic after three months of duration. This lowered her threshold for pain, leading to central sensitization. To correct her central pain syndrome, the sacroiliac joint pathology must be corrected. The initial management for this case would be a trial of physical therapy.
  • If there is a failure to correct the origin of chronic pain, the best step in management for a patient with central sensitization would be a trial of antidepressants such as duloxetine. Given that she is considering pregnancy, medications should only be considered if she agrees to delay conception.
95
Q

A 68-year-old male with a history of prostate cancer presents to the emergency department with acute onset low back pain, which is constant and worst at nighttime. The appropriate imaging test to evaluate for metastatic involvement of the spine is ordered. Which of the following is the most rational pathogenesis underlying the metastatic spread of prostate cancer postulated in the patient?
1. Arterial hematogenous dissemination
2. Lymphatic spread
3. Direct invasion of the spine
4. Spread through Batson’s venous plexus

A

4. Spread through Batson’s venous plexus

  • Along with lung cancer and multiple myeloma, prostate cancer is one of the top three malignancies associated with metastatic spinal cord compression. Metastatic spread of prostate cancer is hematogenous in nature.
  • Unlike other sources of hematogenous spread, pelvic tumors, including prostatic malignancies, are postulated to metastasize via Batson venous plexus, a network of valveless veins that shunts venous blood to the spinal epidural venous plexus during a Valsalva maneuver such as sneezing, coughing, or bearing down.
  • Patients with metastatic spinal cord compression most commonly present with isolated back pain. Any patient with active malignancy and new-onset back pain should be evaluated for the possibility of metastatic spinal disease.
  • Direct extension of paraspinal malignancy into the spinal canal is most commonly seen with lymphoma, which accesses the spinal canal via neural foramina.
96
Q

A 42-year-old woman complains of the sudden onset of a severe headache after a brief period of unconsciousness. Examination reveals a stiff neck, photophobia, and dilated pupil. There was no trauma. Which type of vascular event has most likely occurred?
1. Subdural hematoma
2. Epidural hematoma
3. Carotid dissection
4. Ruptured intracranial aneurysm

A

4. Ruptured intracranial aneurysm

  • Sudden onset of very severe headache with photophobia is the classic presentation of SAH (subarachnoid hemorrhage) in which 85 percent of the time cerebral angiography (CT or MR) will reveal one or more aneurysms.
  • Most neurosurgeons recommend immediate surgery to avoid complications of rebleeding and treat vasospasm more aggressively. Surgical options today increasingly include endovascular percutaneous options.
  • SAH is graded on Hunt and Hess scale I-V with I being minimum symptoms and V being deep coma with poor prognosis.
  • AVMs are also possible causes of SAH, but much less common than cerebral aneurysms.
97
Q

A 53-year-old female with a past medical history of bronchial asthma and dermatitis presents to the primary care physician due to headaches and pulsatile tinnitus for the past six months. The patient undergoes a gadolinium contrast-enhanced brain magnetic resonance imaging, which depicts a large right-sided jugular foramen paraganglioma with avid contrast enhancement. Which of the following will most likely be found in this patient’s otoscopic examination?
1. Normal right and left ear otoscopic examination
2. Right ear tympanic membrane perforation
3. A pulsatile red middle ear mass behind the right tympanic membrane
4. Isolated right tympanic membrane hypervascularity

A

3. A pulsatile red middle ear mass behind the right tympanic membrane

  • The most common finding on physical examination of a glomus jugulare is a pulsatile red middle ear mass behind an intact tympanic membrane during the otoscopic examination.
  • The tympanic membrane can show increased vascularity, and with an inferiorly based red ear mass, the characteristic rising sun appearance is demonstrated.
  • Sometimes, the tympanic portion of the tumor may erode into the ear canal, resulting in bloody otorrhea.
  • Because of their vascularity, pulsatile tinnitus is often the presenting symptom. Hearing loss occurs in 50% of these individuals and the tumors also have the potential to secrete catecholamines.
98
Q

A 34-year-old man complains about left-leg pain that started two weeks ago. The pain intensity is rated as 7 out of 10, starting from the gluteal region to the lateral leg and foot. What is the best initial step in the management of this patient?
1. Perform a straight leg raise test to assess a possible L5 nerve root irritation
2. Request an urgent MRI to assess the possibility of a disc herniation
3. Request a CT scan to evaluate a possible lumbar fracture
4. Give NSAIDs

A

1. Perform a straight leg raise test to assess a possible L5 nerve root irritation

  • Based on the clinical scenario, the best initial step is to perform a straight leg raise test, as this maneuver could help assess the possibility of L5 nerve root irritation.
  • The patient is probably affected by a lumbar disc herniation. The most important step is to evaluate nerve root irritation through the straight leg raise test.
  • The presence of leg pain irradiated from the gluteal region to the foot may indicate a nerve root compromise in the lumbosacral region; the clinical examination is the most crucial step, motor and sensitive exam and nerve irritation maneuvers such as straight leg raise test are the most important tools at this moment.
  • Based on this clinical scenario, the most common cause is a lumbar disc herniation that compromises the L5 nerve root; the next step is to perform a straight leg raise test to assess L5 nerve root irritation. MRI is an important imaging study in this case but is not the next step. Usually, MRI is indicated when there is a motor weakness or after six weeks of conservative management. CT scan is not typically requested in this case. NSAIDs are important in the management of this case. However, the next step is to perform the Straight leg raise test.
99
Q

A 28-year-old woman presents with new-onset spells that start with an epigastric rising sensation followed by fidgety behavior, picking at clothes with her hands, and repetitive swallowing lasting for about a minute. She reports that she is able to talk and respond to questions during the spell. A 1.5 Tesla brain MRI was unremarkable, and a routine EEG showed temporal intermittent rhythmic delta activity (TIRDA). What is the most likely cause of her spells?
1. Psychogenic nonepileptic spells
2. Non-dominant temporal lobe onset seizures
3. Dominant temporal lobe onset seizures
4. Motor tics

A

2. Non-dominant temporal lobe onset seizures

  • The description is typical of temporal lobe seizure. Lip-smacking is probably the most common type of oroalimentary automatism observed, but other forms of oroalimentary automatism like repetitive swallowing or chewing may also be seen.
  • Preserved speech and comprehension indicate nondominant temporal lobe seizure; however, speech arrest is not a reliable localization finding.
  • Temporal intermittent rhythmic delta activity (TIRDA) has a strong correlation with temporal lobe onset seizures.
  • A normal brain MRI does not rule out the possibility of seizure.
100
Q

A 42-year-old female presented with dysphagia. A lytic and exophytic tumor centered in the body of the second cervical vertebra was found on imaging. A needle biopsy demonstrated bubbly cells separated into lobules with fibrous septa and a myxoid stroma. Which of the following stains is expected to be positive in this tumor?
1. S100
2. CK7
3. CK20
4. Chromogranin

A

1. S100

  • Chordomas are benign but locally aggressive tumors with high recurrence rates which arise from the notochord.
  • Chordomas are classically described as lobules or cords of physaliferous cells separated by fibrous septa and the presence of extensive myxoid stroma.
  • There is a high propensity for chordomas to seed along biopsy tracts or recur locally.
  • Chordomas are S100 positive and negative for CK7, CK20, and chromogranin.