Section 9: CNS UW & KMTB

Question 1

Patients with primary hypothyroidism are predisposed to get other autoimmune diseases such as pernicious anemia. Vit B12 deficiency in pernicious anemia is due to a deficiency of intrinsic factor secreted by the stomach.

List the characteristic neurologic involvement in vit B12 deficiency

Answer 1

• Subacute combined degeneration of the spinal cord
• Peripheral neuropathy

Question 2

List the typical features associated with medial medullary syndrome

Answer 2

• Contralateral spastic hemiplegia
• Contralateral vibratory and proprioception loss
• Tongue deviation to the injured side

Question 3

A lesion of the lateral pons can cause lateral midpontine syndrome. List the features of lateral midpontine syndrome

Answer 3

• Impaired sensory and motor function of CN V (the trigeminal nerve)
• Limb ataxia

Question 4

An ischemic lesion of the medial pons can cause medial midpontine syndrome. List the common characteristics of medial midpontine syndrome

Answer 4

• Ipsilateral limb ataxia
• Contralateral eye deviation
• Contralateral paralysis of the face, arm and leg
• Impairment of touch and position sense is variable

Question 5

A lesion of the lateral medulla may result in well-known abnormalities such as Wallenberg syndrome. List the typical features of Wallenberg syndrome.

Answer 5

• An ipsilateral Horner syndrome
• Ipsilateral loss of pain and temperature sensation of the face
• Ipsilateral weakness of the palate, pharynx, and vocal cords
• Cerebellar ataxia
• Contralateral loss of pain and temperature sensation of the body

Question 6

Lesions in the central midbrain can cause a number of different syndromes, including Weber’s syndrome, Benedikt’s syndrome, Claude’s syndrome, Nothnagel’s syndrome, and Parinaud’s syndrome. List features common to lesions in the central midbrain.

Answer 6

• Oculomotor paresis and other abnormalities of CN III function are common to all these syndromes
• Cerebellar ataxia may be noted
• Contralateral hemiplegia may be noted

Question 7

Tick paralysis is caused by Dermacentor andersoni (the Rocky Mountain wood tick), and D. variabilis (the American dog tick). Symptoms develop 5-6 days after a female tick attaches to the patient. The typical presentation is a progressive ascending paralysis that occurs over a matter of hours to days.

True or False:

1. Fever is typically not present
2. Pupillary abnormalities are uncommon
3. Removal of the tick(s) will cause a substantial improvement of the paresis within several hours
4. Sometimes, paralysis may worsen over 24 to 48 hours after the removal of the tick (I. holocyclus). In such cases, careful observation and supportive therapy should be provided

Answer 7

1. True
2. True
3. True
4. True

Question 8

Lewy body dementia

True or False:

1. Visual hallucinations are a prominent symptom in many patients
2. Visual hallucinations can be exacerbated by therapy with dopamine agonists

Answer 8

1. True
2. True

Question 9

1. Patients with acute ischemic stroke and CT scan of the head negative for hemorrhage who are treated with tissue plasminogen activator should not receive what medications within the first 24 hours
2. Strict control of BP with intravenous medications, such as labetelol, nitroprusside, or nicardipine, is recommended to keep BP at ……….

Answer 9

1. Antiplatelet therapy, anticoagulation, or invasive testing
2. 180/105 mmHg

Question 10

10. The DSM-IV Criteria for the diagnosis of opiod withdrawal are the presence of three or more of the following symptoms following reduction in or cessation of a prolonged and excessive opiod use. List them

Answer 10

• GI symptoms such as nausea or vomiting, diarrhea and abdominal cramps
• Myalgias
• Lacrimation or rhinorrhea
• Piloerection, sweating or pupillary dilatation
• Insomnia
• Autonomic symptoms such as HTN and tachycardia

Question 11

Name the centrally acting antihypertensive that is frequently used for the Rx of opioid withdrawal symptoms, either orally in divided doses or as a transdermal patch

Answer 11

Clonidine

Question 12

To correctly diagnose and treat patients with chronic headaches, the characteristics of the headaches must be clarified. Such patients should be instructed to make a headache diary for one week, and this should include the headaches’……., ………, ………, …… ……… and ……….. used

Answer 12

To correctly diagnose and treat patients with chronic headaches, the characteristics of the headaches must be clarified. Such patients should be instructed to make a headache diary for one week, and this should include the headaches’ frequency, duration, intensity, associated symptoms and medications used

Question 13

DOC for prevention of cluster headaches? List two other alternatives

Answer 13

13. Verapamil is the agent of choice for prevention of cluster headaches because it is relatively well tolerated with few side effects and has been evaluated in a randomized controlled clinical trial. Prednisone and lithium are both alternative agents

Question 14

Pineal tumor classically presents with Parinaud’s syndrome, which is characterized by the loss of pupillary reaction, vertical gaze paralysis, the loss of optokinetic nystagmus, and ataxia. Some pineal tumors are germinomas that can secret HCG

Answer 14

Pineal tumor classically presents with Parinaud’s syndrome, which is characterized by the loss of pupillary reaction, vertical gaze paralysis, the loss of optokinetic nystagmus, and ataxia. Some pineal tumors are germinomas that can secret HCG

Question 15

List the features of non-dominant parietal lobe damage

Answer 15

1. Construction apraxia: marked difficulty in copying simple line drawings
2. Dressing apraxia: difficulty wearing clothes, and appear to struggle while attempting to get into a coat or pants
3. Confusion may also be present

Question 16

Damage to the dominant parietal lobe, especially the inferior parietal lobe, presents as Gertsman syndrome. List the features.

Answer 16

1. Difficulty in performing simple arithmetic tasks (acalculia)
2. Inability to name individual fingers (finger agnosia)
3. Impaired writing (agraphia)
4. Right/left confusion (difficulty in identifying or distinguishing the right or left side of the body)

Question 17

List the features of lesions of the non-dominant temporal lobe

Answer 17

1. Visual disorders (homonymous upper quadrantanopia)
2. Impaired perception of complex sound (auditory agnosia)

Question 18

List the features of dominant temporal lobe lesion

Answer 18

1. Homonymous upper quadrantanopia
2. Aphasia (Wernicke’s type)

Question 19

True or False:

Speech and swallowing evaluation, followed by diet modification, is performed in high-risk patients to prevent future episodes of aspiration

Answer 19

True.

PEG tube placement does not prevent aspiration

Question 20

Caloric stimulation of the vestibular apparatus is performed by irrigation of the external auditory canal with cold water.

Describe a normal response

Answer 20

A normal response is characterized by a transient, conjugate, slow deviation of gaze to the side of the stimulus (brain-stem mediated), and followed by saccadic correction to the midline (cortical correction). A caloric response cannot be voluntarily suppressed; therefore a normal oculovestibular reaction in a comatose patient strongly suggest psychogenic coma

Question 21

List the different syndromes associated with central midbrain lesions

Answer 21

1. Weber Syndrome
2. Parinaud Syndrome
3. Benedikt Syndrome
4. Claude’s Syndrome
5. Nothnagel’s Syndrome

Question 22

Diagnosis:

• Unilateral headache
• Miosis
• Ptosis
• Anhidrosis

Best initial diagnostic test for above diagnosis

Most accurate diagnostic test

Answer 22

Carotid dissection

MRA of the head and neck

Catheter angiography

Question 23

A 65 year-old female presents to the emergency room with a chief complaint of headache. Upon further questioning, she states that the headache is localized to the right side of her head. The patient has no other complaints. Her only regular medications are acetamenophen for arthritis in her left shoulder and metformin for recently diagnosed DM Type II. On physical examination you notice that the patient’s right pupil is smaller than the left and her right eyelid is slightly drooping. Initial lab reveal:

Hemoglobin 12.2g/L

Platelets 206,000/mm³

Leukocyte count 4,500/mm³

ESR 20 mm/hr

What is the next best test in the management of this patient?

• A. CT head without contrast
• B. MRA of the head and neck
• C. Begin oral prednisone
• D. Order temporal artery biopsy
• E. Perform lumbar puncture

Answer 23

This patient has a unilateral headache with associated Horner’s syndrome, which consists of miosis (small pupil), ptosis (eyelid drooping), and often anhidrosis (lack of sweating) on the affected side. This patient should be considered to have carotid dissection until proven otherwise. The key to the presentation is the presence of Horner’s syndrome, which occurs because the sympathetic chain providing innervation to the head travels on the carotid artery. Carotid artey dissection can be due to trauma, connective tissue disease, smoking, neck manipulation, HTN, and three point restraint seatbelts in motor vehicle accidents. Once the carotid artery dissection is suspected, the preferred method of noninvasive imaging is MRA. If the MRA results are unclear but carotid dissection is still suspected, catheter angiography is the definitive test. These patients are at high risk of developing cerebral infarction. Treatment consists primarily of anticoagulation with platelet agents and/or heparin