Neurology Vignettes

Karen wasn't feeling well all of a sudden. She had a headache, she was nauseous, and when she tried to ask her husband to take her to the hospital, she had trouble finding and speaking her words. She pantomimed, and he eventually got the picture. An MRI with contrast revealed multiple enhancing lesions in her brain, so Karen's Neurology PA ordered a PET scan of her body. Of the choices below, what did the PET scan most likely reveal? A. a large tumor in one of her lungs B. arterial bleeding between her skull and dura C. small tumors in her left ovary D. focal weakness

a large tumor in one of her lungs

Your 50 y/o pt tells you they are adopted and have an unknown family history, and are concerned because last year they were diagnosed with an essential tremor and were unsuccessfully treated, and is having more motor movements than before, and saw on WebMD something called Huntington's disease. You perform a neurological exam and find tremors that are more progressed unilaterally, rigidity, shuffled gait, and increased tone in his limbs. What will his MRI show? A. Caudate atrophy B. White matter focal lesions C. Brain imaging is normal D. Atrophy of substantia nigra

Brain imaging is normal

A 78-year-old right-handed male is brought in by ambulance after being found down in his home. After being aroused, the patient has difficulty answering questions and appears to be frustrated by his inability to communicate. He is able to speak his name and a few other words but his speech is not fluent. Subsequent neurologic exam finds that the patient is able to comprehend both one and two step instructions; however, he is unable to repeat phrases despite being able to understand them. He also has difficulty writing despite retaining fine motor control. CT reveals an acute stroke to his left hemisphere. Damage to which of the following sets of structures would be most likely to result in this pattern of deficits?

Broca Aphasia

An 82-year-old right-handed woman is brought in by ambulance after being found down in her home. On presentation, she is found to be awake but does not follow directions or respond to questions. She is able to speak and produces a fluent string of nonsensical words and sounds. She does not appear to be bothered by her deficits. Subsequent neurologic exam finds that the patient is unable to comprehend any instructions and is also unable to repeat phrases. CT scan reveals an acute stroke to her left hemisphere.

Wernicke aphasia

You are assessing a patient who recently experienced a partial seizure. As the physician assistant, you know that which statement by the patient indicates the patient may have experienced a focal impaired awareness (complex partial) seizure? A. "My friend reported that during the seizure I was staring off and rubbing my hands together, but I don't remember doing this." B. "I remember having vision changes, but it didn't last long." C. "I woke up on the floor with my mouth bleeding." D. "After the seizure I was very sleepy, and I had a headache for several hours."

"My friend reported that during the seizure I was staring off and rubbing my hands together, but I don't remember doing this."

____________ is a muscarinic blocker used to treat Parkinson disease.

*Benztropine* "Park my Benz"

_______________ and _______________ are two COMT inhibitors used in Parkinson disease that prevent peripheral levodopa degradation to 3-O-methyldopa.

*Entacapone* and *tolcapone* "The Capones Control the COMTs" COMT: Catechol-O-methyltransferase

Your patient is 65 years old and C/O intermittent neurologic dysfunction and speech disturbances that lasted for 30 minutes. You immediately think it may be from a transient ischemic attack (TIA). What is the patient's ABCD2 score and risk of stroke? Patient is not on any medications and has no significant PMH. BP: 136/82. Physical Exam shows no weakness. A. 6, High risk B. 4, Moderate risk C. 3, Moderate risk D. 3, Low risk

3, Low risk

The average age of onset for Huntington disease is _____years of age.

40

A 42-year-old woman comes to the clinic because of worsening coordination. She says she often falls over, cannot button up her shirts, and has difficulty swallowing. Physical examination shows slightly slurred speech and intermittent repetitive, wide circular movements of her arms. Her daughter, who is present, tells you that her mother has also lost speed and flexibility in thinking. Most of the time she seems depressed and lately she has been quite difficult to get along with; persistently focusing on minutiae and perseverating on repetitive, superstitious behaviors. Which of the following genetic findings is most consistent with this presentation? A >40 CAG repeats in the HD gene B>100 CTG repeats in the OSCA gene C>100 GAA repeats in the FXN gene D>200 CGG repeats in the FMR1 gene E>200 CTG repeats in the DMPK gene

>40 CAG repeats in the HD gene Huntington disease is a neurodegenerative disease of the trinucleotide repeat (CAG) family. It is characterized by chorea, dementia, and personality/behavioral changes.

Which of the following fibrinolytic agents can be used in patients with acute ischemic stroke? A. Alteplase (recombinant tissue plasminogen activator) B. Streptokinase C. Urokinase D. Tenecteplase

Alteplase

A 64-yr-old female comes to your office complaining of new worsening HA, some weakness and sudden nausea & vomiting. You order a CTH and notice multiple lesions in the brain. What is your next step in diagnosing this patient? A. Biospy B. Lumbar puncture C. Cerbral angiography D. Full body scan

Full body scan

____________ is a synaptic protein involved in vesicular production that accumulates in Lewy body dementia and Parkinson disease.

Alpha-synuclein

A 9 - year-old male patient is being evaluated for seizures. While in the child's room talking with the child's parents, you notice that the child appears to be daydreaming. You time this event to be 10 seconds. After 10 seconds, the child appropriately responds and doesn't recall the event. This is known as what type of seizure? A. Focal Impaired Awareness (complex partial) B. Atonic C. Tonic-clonic D. Absence

Absence

A 6-year-old female without significant past medical history presents for evaluation of frequent unusual episodes for the past 3 months. The unusual episodes consist of sudden activity arrest with staring and minimal eyelid flutter for 10 to 20 seconds occurring 5 to 10 times per day. The patient is unresponsive to voice or tactile stimulation during the episodes. She is able to immediately resume activities without any recollection of the event once the episode finishes. Her teachers have noted that she stares off in class repeatedly and does not seem to be remembering instructions and classroom material. The diagnosis of attention-deficit/hyperactivity disorder had been suggested. One such unusual episode is induced in front of medical staff with hyperventilation.

Absence Seizure

A 6th grade student is at school and feeling very anxious about an upcoming test today. During lunch prior to the test, he was talking to his friend, when all of the sudden his friend explained that he started staring into space, while sitting upright, and not responding to the questions he was asking him. His friend started tapping him on the shoulder, but he didn't react. The friend reports this lasted about 30 seconds. When his friend told him this after he was alert again, he didn't believe that had just happened. What type of neurological issue might this student have? A. ADHD B. Generalized Tonic/Clonic Seizures C. Absence Seizures D. Status Epilepticus

Absence Seizures

Mother presents to your office concerned that her 8 year old child is not paying attention during class. She reports the child's teacher says he is often staring into space blinking repeatedly and doesn't respond to questions. She is concerned that he may have a learning disability. What is in your differential and what test will you order? A. Hearing loss, audiogram B. Absence seizure, EEG C. Tourette's disorder, no diagnostic testing D. Generalized anxiety disorder, psychiatric referral

Absence seizure, EEG

A 49-year-old man presents to his primary care provider complaining of weakness and fatigue. He reports that he has started moving slower than normal and has noticed difficulty buttoning up his pants or tying his tie. He is accompanied by his wife who reports that he has started to move more slowly over the past 2 years. He has also become increasingly irritable and has had trouble sleeping. His past medical history is notable for hypertension, diabetes mellitus, and obesity. He takes enalapril and metformin. His family history is notable for multiple strokes in his mother and father. His temperature is 99°F (37.2°C), blood pressure is 140/90 mmHg, pulse is 90/min, and respirations are 17/min. On exam, strength is 4+/5 bilaterally in his upper extremities and 4/5 in his lower extremities. Some muscle atrophy is noted in his legs and feet. Patellar reflexes are 3+ bilaterally. He has a tremor in his right hand that diminishes when he is instructed to hold a pen in his hand. He is oriented to person, place and time. He states that he feels depressed but denies suicidal ideation. His physician prescribes multiple medications including a drug that is also indicated in the treatment of prolactinomas. Which of the following is the mechanism of action of this medication? Activate dopamine receptors Increase dopamine release Inhibit dopamine receptors Prevent dopamine degradation into 3-O-methyldopa Prevent dopamine degradation into 3,4-dihydroxyphenylacetic acid

Activate dopamine receptors The patient in this vignette presents with a resting tremor and bradykinesia suggestive of Parkinson disease. Bromocriptine is a dopamine agonist that is used to treat Parkinson disease and prolactinomas. The primary metabolic disturbance in Parkinson disease is decreased dopamine signaling. Bromocriptine is a dopamine receptor agonist that is used to restore the balance in dopamine signaling in Parkinson disease. It is also used to treat hyperprolactinemia in the setting of a prolactinoma. Dopamine inhibits prolactin secretion, so dopamine agonists such as bromocriptine and cabergoline effectively inhibit excess prolactin secretion.

A 51-year-old man presents to the emergency department due to headache, nausea, and pupillary abnormalities after a physical altercation. The patient was in his usual state of health until there was a fight that resulted in head trauma. Medical history is significant for hypertension and chronic alcohol abuse disorder of over 15 years, which is treated with hydrochlorothiazide and disulfiram. His blood alcohol level is 0.32%. On physical examination, the patient appears confused and a dilated pupil that is unresponsive to light. A non-contrast head CT is shown.

Acute subdural hematoma

A 70 year old man was brought in the ED for left sided weakness for 1 hr. The reports that he suddenly could not move his leg at home. Pt denies history of bleeding disorders or recent surgery but admits to PMHx of hypercholesterolemia, HTN, AFib, and tobacco use. His PE shows 5/5 strength in LUE and 1/5 strength in LLE with a decrease in sensation in the left leg and foot. CT showed no hemorrhages. What is the next best step in treatment? A) Alteplase B) ASA C) Clopidogrel D) Warfarin

Alteplase

Lack of ability to recognize significance of sensory stimuli Agnosia Athetosis Agraphia Dysmetria

Agnosia

Inability to express thoughts in writing due to a central lesion Agnosia Athetosis Agraphia Dysmetria

Agraphia

Lack of spontaneous movement Athetosis Ataxia Apraxia Akinesia

Akinesia

P/w mood lability, impaired judgment, inappropriate aggressive and sexual behavior, nystagmus, ataxia, and slurred speech

Alcohol Intoxication

The on-call physician is called to see a 46 yo M patient because of seizures. The patient was admitted to the surgical ward two days ago, after emergency trauma surgery. The nurse reports that the patient was anxious, agitated, irritable, and tachycardic last night. Later on, the nurse noted nausea, diarrhea, sweating, and insomnia. The patient had tremors, startle response, and hallucinations earlier tonight VS: T 37°C (99°F), P 133, BP 146/89, RR 22, O2 sat 92% room air Gen: Sweating; cigarette burns on hands; multiple tattoos and rings Chest: WNL Abd: Hepatomegaly Ext: Evidence of recent surgery Neuro: Tremor, confusion, delirium, clouded sensorium, and evidence of peripheral neuropathy

Alcohol Withdrawal

Increased anion gap acidosis Hypoglycemia P/w altered mental status, N/V Anion-gap metabolic acidosis

Alcoholic Ketoacidosis

A mother comes in c/o unusual behavior/language in her 14 y/o daughter, Lindsay. Mom reports random episodes of angry cursing and mocking of her words, and wants to know if there is something wrong with her brain as Lindsay denies having any control over her actions during these episodes. What are possible courses of treatment for Lindsay? a. Behavioral therapy and reassurance that most patients outgrow this disorder by adulthood b. Alpha adrenergic agonists c. Antipsychotics d. Surgery e. Botulinum toxin f. All of the above

All of the above

A 70-year-old man is brought to the emergency department because of left-sided weakness for one hour. The patient reports that he suddenly could not move his left leg at home. The patient denies any history of a bleeding disorder, active bleeding, or recent surgery. His past medical history is significant for hypercholesterolemia, hypertension, atrial fibrillation, and tobacco abuse. Physical examination shows 5/5 strength in the left upper extremity and 1/5 strength in the left lower extremity. There is decreased sensation in the left leg and foot. A computed tomography scan of the brain shows no hemorrhages. Which of the following is the next best step in management? A. Alteplase B. Aspirin C. Clopidogrel D. Unfractionated heparin E. Warfarin

Alteplase Altepase is a tissue plasminogen activator (tPA). These medications should be given to patients with symptoms of stroke within 3-4.5 hours of initial onset.

A 67-year-old woman was admitted to the hospital for extreme confusion and agitation. She had been doing reasonably well until 3-4 weeks prior to admission; however, her family says that her memory has been getting worse over the last 3 years. Initially, she had problems remembering recent events and people's names and had a tendency to dwell in the past. She got lost several times while driving, most recently in a familiar neighborhood. She has stopped cooking because she can no longer work her electric oven. Sometimes her words don't make sense. Her social graces have remained preserved, however, and she is still quite pleasant to be around, although she tends to interact socially less and less. She still walks around the block every day, and her basic gait and coordination seem quite normal. Because she was crying intermittently recently, her family doctor began her on a progressively increasing dose of amitriptyline 1 month ago. Initially, she began sleeping well at night, but the last few days she has been having visual hallucinations and shouting incoherently. On physical examination she was mildly tachycardic. She was inattentive and had difficulty keeping on task. Her speech revealed numerous paraphasic errors but was otherwise fluent. Her neurologic examination was otherwise unremarkable.

Alzheimer

A 73-year-old man is brought in by his wife with concerns about his worsening memory. He is a retired engineer who has recently been getting lost in the neighborhood where he has lived for 30 years. He has been found wandering and has often been brought home by neighbors. When asked about this, he becomes upset and defensive and states that he was just trying to get some exercise. He has also had trouble dressing himself and balancing his checkbook. A physical examination is unremarkable, except that he scores 12 points out of 30 on the Mini-Mental Status Examination, a test of cognitive function. A metabolic workup is normal. A computed tomography scan of the head shows generalized brain atrophy, though perhaps only what would be expected for his age. He is diagnosed with dementia, likely from Alzheimer disease.

Alzheimer

A 54-year-old black woman is referred to the neurology clinic by her primary care physician for evaluation of memory problems. The patient is brought to the clinic by family members who are concerned that she has been forgetful in the past year. They report that she has difficulty in recalling birthdays and anniversaries and is not managing common household tasks such as cooking and paying bills. The patient's sister had onset of dementia in her early 40s and was institutionalized because she was unable to care for herself. The patient was last seen by her primary care physician 3 months ago, when she had a routine workup, which was reported to be unremarkable. Neurologic examination revealed no significant abnormalities. Neuropsychological testing demonstrated severe impairment in executive function, deficits in visuospatial testing, and delayed speed of processing information. Mini-Mental State Examination (MMSE) score is 20/30.

Alzheimer Dementia

65-y/o presents with a gradual decline in memory and inability to complete activities of daily living; W/U: CT shows marked enlargement of ventricles and diffuse cortical atrophy.

Alzheimer Disease

84 yo F brought in by her son complains of forgetfulness (e.g., forgets phone numbers, loses her way home) along with difficulty performing some of her daily activities (e.g., bathing, dressing, managing money, answering the phone). The problem has gradually progressed over the past few years. VS: P 90, BP 120/60, RR 12 Gen: NAD Lungs: WNL CV: WNL Abd: WNL Ext: WNL Neuro: On mini-mental status exam, patient cannot recall objects, follow three-step commands, or spell "world" backward; cranial nerves intact; strength and sensation intact

Alzheimer Disease

A 78-year-old man presents to his primary care clinic and is accompanied by his wife. He feels well, but his wife is concerned that he has become more confused over the past few weeks. He enjoys socializing with family and friends, but sometimes has difficulty finding words and recently forgot his niece's name. He walks around his neighborhood for exercise, but has the tendency to wander and get lost. He has a history of hypertension and atrial fibrillation. Current medications are warfarin and dronedarone. Physical exam is unremarkable. Recent lab results were within normal limits.

Alzheimer Disease

A 76-year-old white woman is brought to the physician by her children because she is becoming more forgetful. She used to pay her bills independently and enjoyed cooking but has recently received overdue notices from utility companies and found it difficult to prepare a balanced meal. She has lost 3.5 kg in the past 3 months, and left the water running in her bathtub and flooded the bathroom. When her children express their concerns, she becomes irritable and resists their help. Her house has become more cluttered and unkempt. On a past visit to her physician, she had normal laboratory tests for metabolic, hematologic, and thyroid function. The current evaluation reveals no depressive symptoms and 2/15 on the Geriatric Depression Scale short-form. Her Mini-Mental State Examination (MMSE) score is 20/30.

Alzheimer's Dementia

______________ is a weak N-methyl-D-aspartate receptor antagonist in the treatment of Parkinson disease.

Amantadine

A 75-year-old female with hypertension presents to the emergency room with one hour of slurred speech. Her symptoms resolve while she is waiting to see the physician. Which of the following tests is NOT part of the initial work-up for this condition? Electrocardiogram Non-contrast head CT scan Carotid doppler Transthoracic echocardiogram Ambulatory cardiac event monitor

Ambulatory cardiac event monito Any patient with a suspected transient ischemic attack (TIA) should undergo urgent evaluation due to the high risk of a subsequent stroke. Work-up should include ECG, non-contrast head CT, carotid doppler, and an echocardiogram.

A 72 y/o man with a with a PMHx of diabetes mellitus, renal insufficiency, and HTN presents to the clinic complaining of burning and tingling pain in his feet. What agent would you prescribe? a) Phenobarbital b) Amitryptyline c) Celecoxib d) Codeine

Amitryptyline

A 61-year-old male presents with left-sided hand weakness and trouble with walking. He is not sure why these symptoms occur. On physical exam, tongue fasciculations are appreciated. He has slow speech. The left upper extremity shows forearm atrophy and depressed reflexes. The right lower extremity is hypertonic, with 3+ reflexes and positive Babinski sign.

Amyotrophic Lateral Sclerosis

A 70 y/o male presented with difficulty with swallowing, chewing, and speaking. PE reveals loss of ability to initiate and control motor movements. Electromyography which shows widespread denervation changes. What is the likely diagnosis in this patient? A. Amyotrophic Lateral Sclerosis (ALS) B. Tourette disorder C. Trigeminal neuralgia D. Bell Palsy

Amyotrophic Lateral Sclerosis (ALS)

A 61-year-old man is brought to the emergency room with slurred speech. According to the patient's wife, they were watching a movie together when he developed a minor headache. He soon developed difficulty speaking in complete sentences, at which point she decided to take him to the emergency room. His past medical history is notable for hypertension and hyperlipidemia. He takes aspirin, lisinopril, rosuvastatin. The patient is a retired lawyer. He has a 25-pack-year smoking history and drinks 4-5 beers per day. His father died of a myocardial infarction, and his mother died of breast cancer. His temperature is 98.6°F (37°C), blood pressure is 143/81 mmHg, pulse is 88/min, and respirations are 21/min. On exam, he can understand everything that is being said to him and is able to repeat statements without difficulty. However, when asked to speak freely, he hesitates with every word and takes 30 seconds to finish a short sentence.

Anterior cerebral artery and middle cerebral artery watershed area

A 45-year-old female comes to the emergency department because of a severe headache for 20 minutes. She states that she often gets headaches, but that this one feels different. Medical history includes hypertension. CT-scan is obtained. Lumbar puncture shows xanthochromia. Which of the following is the most likely vasculature associated with her condition? A. Anterior communicating artery and anterior cerebral artery junction B. Middle cerebral artery and internal carotid artery junction C. Middle meningeal artery D. Posterior cerebral artery and basilar artery junction E. Posterior cerebral artery and posterior communicating artery junction

Anterior communicating artery and anterior cerebral artery junction Subarachnoid hemorrhages are most commonly caused by ruptured berry aneurysms and bleeding arteriovenous malformations. The most common location for a ruptured berry aneurysm is the junction of the anterior communicating artery and anterior cerebral artery.

A 75-year-old woman comes to the emergency department because of weakness and hyperreflexia in her right arm and leg for the past hour. Neurological examination shows loss of right sided vibratory sensation and proprioception and deviation of the tongue towards the left. Which of the following vessels is most likely involved in this patient's condition? A. Anterior spinal artery B. Right middle cerebral artery C. Right anterior cerebral artery D. Left posterior inferior cerebellar artery E. Anterior communicating artery

Anterior spinal artery Medial medullary syndrome is caused by an infarct of the anterior spinal artery. Medial medullary syndrome is characterized by contralateral muscle weakness, ipsilateral tongue deviation, and contralateral loss of sensation from the body, sparing the face.

______________ are a class of drugs useful for treating the postural instability in Parkinson disease.

Anticholinergics

Inability to carry out purposeful movement in the absence of paralysis Athetosis Ataxia Apraxia Akinesia

Apraxia

A 53-year-old man with a past medical history of hypertension and hyperlipidemia is hospitalized following an ischemic stroke. He is alert and responsive. On initial neurological exam, he is asked to stick out his tongue. He looks puzzled, as if he is trying very hard to follow the instruction but cannot. Two minutes later he sticks his tongue out spontaneously. Which of the following is the most likely diagnosis? A. Expressive aphasia B. Agnosia C. Astereogenesis D. Abulia E. Apraxia

Apraxia is a disorder of higher-order motor control leading to difficulty performing skilled movements. It is not due to a problem with the primary motor systems or due to a lack of understanding.

A 48-year-old man presents to the ER with a sudden-onset, severe headache. He is vomiting and appears confused. His wife, who accompanied him, says that he has not had any trauma, and that the patient has no relevant family history. He undergoes a non-contrast head CT that shows blood between the arachnoid and pia mater. What is the most likely complication from this condition? Blindness Arterial Vasospasm Hemorrhagic shock Bacterial Meningitis Renal failure

Arterial Vasospasm The patient has had a subarachnoid hemorrhage (SAH), and arterial vasospasm is the most common complication from this disease.

Per EMS report the patient, a 17 Year old female, was standing at her locker at school when she suddenly collapsed and started to seize. Patient has recently been complaining of headaches And her family states that there is a familial history of Sudden brain bleeds. What is the most likely diagnosis and what imaging is the gold standard? A) Hemorrhagic Brain Tumor: CT angiography B) Arteriovenous Malformation: Cerebral angiography C) Subdural Hematoma: CT Scan D) Epidural Hematoma: MRI

Arteriovenous Malformation: Cerebral angiography

what would the EEG show and what treatment do you provide for partial seizures? A. EEG shows 3Hz spike waves; Ethosuximide (Zarontin) B. EEG shows focal discharges; IV Levetiracetam C. EEG is normal; IV Benzodiazepines D. EEG shows focal discharges; immediate surgical resection of seizure focus E. EEG shows generalized spike and wave patterns; Lamotrigine (Lamictal)

EEG shows focal discharges; IV Levetiracetam

Loss of power of muscle coordination Athetosis Ataxia Apraxia Akinesia

Ataxia

Slow writhing movements of distal extremeties Bradykinesia Dyskinesia Myclonus Athetosis Tremor

Athetosis

A 40-year-old woman comes to the office because of involuntary movements of her body that have progressed insidiously and are now interfering with her walking. Her father had similar symptoms when he was 50, with rapid cognitive decline. The patient is found to have the same trinucleotide repeat expansion as her father. Which of the following movement symptoms is she most likely to experience? A. Asterixis B. Tardive dyskinesia C. Athetosis D. Hemiballismus E. Akathisia

Athetosis is a hyperkinetic movement symptom characterized by slow, involuntary, writhing movements. Huntington disease and cerebral palsy are the most common causes.

what would you find on EEG and what treatment would you provide for a patient with generalized tonic-clonic seizures? A. EEG shows 3Hz spike waves; Ethosuximide (Zarontin) B. EEG shows focal discharges; IV Levetiracetam C. EEG is normal; IV Benzodiazepines D. EEG shows focal discharges; immediate surgical resection of seizure focus E. EEG shows generalized spike and wave patterns; Lamotrigine (Lamictal)

EEG shows generalized spike and wave patterns; Lamotrigine (Lamictal)

An 18-year-old male student presents with severe headache and fever that he has had for 3 days. Examination reveals fever, photophobia, and neck stiffness.

Bacterial Meningitis

A 24 y/o male presents to the ER very ill. Patient complains of headache,fever, and nuchal rigidity. Suddenly, he gets confused as he is trying to describe his symptoms. Kernig and Brudzinski sign are positive. Results from the lumbar puncture of CSF are the following: very elevated WBC, protein elevated, and glucose is low. What type of meningitis does the patient have? A) Fungal meningitis B) Bacterial meningitis C) Viral meningitis D) None of the above

Bacterial meningitis

A 1-month-old girl presents to her primary care physician with a high fever that has lasted 24 hours, feeding difficulties, and irritability. Examination reveals altered mental status and a bulging fontanel.

Bacterial Meningitis

A 58-year-old man comes to the emergency department because of unresponsiveness for at least 15 minutes. He was found on the floor by his coworkers after they heard him fall down in his office. They performed CPR while awaiting emergency medical services. His medical history includes factor V Leiden mutation. Physical examination shows spastic paralysis of all four extremities and an inability to produce facial, mouth, or tongue movements. Glasgow coma scale score is 4, and it is determined that the patient is in a coma. Three days later, he exhibits vertical eye movement in response to questions and it is determined that the patient is conscious. Which of the following arteries is most likely infarcted? A. Anterior inferior cerebellar artery B. Anterior spinal artery C. Basilar artery D. Posterior cerebral artery E. Posterior inferior cerebellar artery

Basilar artery Locked-in syndrome is a condition caused by a stroke involving the basilar artery that is characterized by the preservation of vertical eye movement and consciousness in the presence of quadriplegia and loss of voluntary mouth, tongue, and facial movements. These patients are said to be locked in their paralyzed bodies.

A 40-year-old woman wakes with fullness, numbness, and a heavy sensation on the left side of her face. There is no skin hypesthesia (decreased sensitivity). She has slight numbness and loss of taste on the left side of her tongue and mild hyperacusis (hearing sensitivity) in her left ear. Later the same day she notices left ear and facial pain. An incomplete left facial paralysis occurs, making it difficult to keep liquids in her mouth, smile, or close her eye. These symptoms progress to a complete paralysis by the next morning. On physical exam, the left eye is more open than the right, the left nasolabial fold is absent, and the left corner of her mouth droops. On the left side, she cannot voluntarily raise her eyebrow, close her eyelid, elevate her mouth into a smile, snarl, or pucker her lips. The rest of the history and physical exam are normal.

Bell palsy

what is a rescue medication used for partial seizures with a focal discharge? a. Benzo b. Kepro

Benzo

The on-call physician is called to see a 46 yo M patient because of seizures. The patient was admitted to the surgical ward two days ago, after emergency trauma surgery. The nurse reports that the patient was anxious, agitated, irritable, and tachycardic last night. Later on, the nurse noted nausea, diarrhea, sweating, and insomnia. The patient had tremors, startle response, and hallucinations earlier tonight VS: T 37°C (99°F), P 133, BP 146/89, RR 22, O2 sat 92% room air Gen: Sweating; cigarette burns on hands; multiple tattoos and rings Chest: WNL Abd: Hepatomegaly Ext: Evidence of recent surgery Neuro: Tremor, confusion, delirium, clouded sensorium, and evidence of peripheral neuropathy

Benzodiazepines with a taper (ex. chlordiazepoxide, lorazepam) Adequate hydration, correction of electrolyte imbalances (particularly magnesium, calcium, and potassium), and administering the vitamins thiamine ( 100 mg intravenously daily for 3 days then orally daily), folic acid (1 mg orally daily), and one multivitamin orally daily. Thiamine should be given prior to any glucose containing solutions

__________________ and trihexyphenidyl are antimuscarinic medications used in Parkinson disease that likely act within the striatum on cholinergic interneurons, thereby decreasing the cholinergic tone.

Benztropine

A 55 year old man presents to the ER with sudden onset of weakness in both extremities that initiated yesterday. Associated symptoms include paresthesias, absent deep tendon reflexes, and mild loss of cutaneous sensation bilateral lower extremities. Imaging studies shows demyelination. Which of the following is likely diagnosis? A. Myasthenia Gravis B. Transverse Myelitis C. Guillain- Barre syndrome D. Botulism

Guillain- Barre syndrome

A 40-year-old man comes to clinic with difficulty walking. He is an actor and has been having trouble moving around the set. He complains of feeling "off-balance" and has fallen several times. He suffers from occasional headaches for which he takes ibuprofen, but is otherwise healthy. He does not smoke, and takes no medications. He denies blurry vision, neck stiffness, leg pain, nausea, or recent illness. His temperature is 36.6°C (98.3°F), pulse is 85/min, respirations are 16/min, and blood pressure is 116/80 mm Hg. He is a well-appearing young man, sitting comfortably. He repeatedly rubs his right thumb and first digit together. Pupils are equal, round and reactive to light and accommodation. He has no facial droop or ptosis. Gait examination shows that it takes him multiple steps to turn around. He scores 28/30 on Mini-Mental Status Exam. Which of the following therapies is most appropriate for this patient? A. Benztropine B. Dopamine C. Ethosuximide D. Memantine E. Sumatriptan

Benztropine This patient would benefit most from beginning benztropine therapy. An examination revealing shuffling gait and a "pill-rolling" resting tremor, in addition to a history of loss of balance and hypokinesia makes the most likely diagnosis Parkinson's disease (PD). The patient's younger age of onset (below 50 years) may indicate the specific entity of Early-Onset Parkinson's Disease. The initial treatment of PD is levodopa (L-DOPA), a synthetic precursor to dopamine capable of crossing the blood-brain barrier. Other medications that can help control PD include anticholinergics such as benztropine. These drugs help control the cholinergic sensitivity caused by a relative decrease of dopamine. Benztropine helps control tremor, though it is less effective at improving rigidity or bradykinesia.

A 47-year-old male presents to the emergency department with headache. He reports that he suddenly developed a throbbing, bitemporal headache about five hours ago "out of nowhere". He has a history of migraine headaches, but he feels that this headache is significantly more painful than his typical migraines. The patient took his prescribed sumatriptan with no relief in his symptoms. The patient also endorses nausea, and he reports that he vomited once before arrival in the emergency department. The patient denies any recent trauma to the head. His past medical history is significant for migraines and hypertension. He has a 20 pack-year smoking history and a history of cocaine use. He drinks 5-6 beers per week. On physical exam, he appears to be in moderate distress and has pain with neck flexion. He has no focal neurologic deficits. A head CT is performed and can be seen in Figure A. This patient's condition affects which of the following spaces or potential spaces? A. Between periosteum and skull B. Between periosteum and galea aponeurosis C. Between skull and dura mater D. Between dura and arachnoid mater E. Between arachnoid and pia mater

Between arachnoid and pia mater This patient presents with a sudden, severe headache and a head CT showing bleeding in the subarachnoid space, which confirms a diagnosis of subarachnoid hemorrhage. The bleeding in a subarachnoid hemorrhage occurs between the arachnoid and pia mater.

Abnormal slowness of movement Bradykinesia Dyskinesia Myclonus Athetosis Tremor

Bradykinesia

55-y/o with a h/o squamous cell carcinoma of the lung presents with nausea, vomiting, headache, and diplopia; PE: papilledema, left oculomotor palsy, right pronator drift; MRI: multiple round, hyperintense cortical and cerebellar lesions.

Brain Metastases

A 45 y/o male presents with ascending symmetrical paralysis that started in his legs. On PE, the PA determines that the patient has Bell's palsy, ptosis and dysarthria. What is the most likely diagnosis? A) Amyotrophic Lateral Sclerosis B) Huntington's Disease C) Guillain-Barre Syndrome D) Multiple Sclerosis

Guillain-Barre Syndrome

A 17-year-old man presents to the emergency department after a physical altercation that resulted in a stab wound. He was stabbed at level T12 in the back. On physical examination, there is significant muscle weakness affecting the whole right lower extremity. There is also impaired vibration and proprioception sense of the right leg and loss of pain and temperature sense of the left leg.

Brown-Sequard Syndrome

A 21-year-old male presents to the ED with a stab wound to the right neck. The patient is alert and responsive, and vital signs are stable. Which of the following neurologic findings would most likely support the diagnosis of right-sided spinal cord hemisection?

Brown-Sequard syndrome, is characterized by ipsilateral loss of tactile, vibration, and proprioception loss, contralateral pain and temperature sensation loss, and ipsilateral paresis.

A 75-year-old woman with a history of stroke 1 year ago was found unconscious on the floor of her home by her son. The patient was brought to the emergency department by ambulance but expired prior to arrival. An autopsy was performed and showed the cause of death to be a massive ischemic stroke. The coroner also examined sections taken from the area of her prior stroke. Which histologic finding would be prominent in the area of her stroke from one year prior?

By approximately one month after an ischemic infarct, the involved area will have formed a glial scar, which histologically appears as a cyst formed by astrocyte processes.

Which of the following statements regarding carotid endarterectomy (CEA) is (are) true? A. CEA is indicated in the presence of a completed stroke B. CEA is indicated in the presence of a complete arterial occlusion C. randomized, controlled trials have established the benefit of CEA over standard medical therapy for the treatment of carotid artery stenosis D. CEA has been established as the treatment of choice in patients with a documented TIA and a tightly stenotic lesion greater than 70%

CEA has been established as the treatment of choice in patients with a documented TIA and a tightly stenotic lesion greater than 70%

A 46 years old man comes to the emergency department because of the sudden onset of inability to move the right side of his face. Physical examination shows drooping of the corner of the mouth. Motor examination shows difficulty smiling and puffing out the cheeks; no abnormalities are noted in raising the eyebrows or wrinkling the forehead. Which of the following is the most likely the nerve damage of these findings? a. CN 5 b. CN 7 c. CN 10 d. CN 8

CN 7

________ imaging can detect ischemic changes in the brain 6-24 hours following the injury.

CT

A 58 year old asain male patient is rushed into the ER because of a worsening headache , nausea, vomiting, contralateral hemiplegia, and contralateral hemiparesis. He is lethargic and having episodes of altered mental status. His past medical history consists of hypertension. The patient is also a fond user of cocaine. You completed your physical exam and you rate his ICH score to be of a score of 4. What is your diagnostic tool of choice and what does his prognosis look like? A: CT of head , mortality rate of 20% B: CT of head with contrast, mortality rate of 90-100% C: MRI with 100% mortality rate D. CT of head without contrast mortality rate of 90-100%

CT of head without contrast mortality rate of 90-100%

A 37-year-old man comes to the clinic because of speech problems. He is an artist, and a year ago he started experiencing difficulty even holding a pencil. Since then, he constantly drops objects. His wife says his speech symptoms began a few weeks ago. She describes his speech as slow, soft, slurred, and hard to understand. He has also lost interest in daily activities and finds it hard to focus on a single activity. He no longer takes notice of even simple things and forgets to do what are normally daily tasks. His wife tells you that her husband's father had a similar disorder that started when he was 47-years-old. Which of the following parts of the basal ganglia is most likely to have damage? A. Amygdala B. Caudate nucleus C. Claustrum D. Globus pallidus E. Putamen

Caudate nucleus Huntington disease is a progressive neurodegenerative condition characterized by a classic movement abnormality called chorea, which is due to neuronal cell loss predominantly in the caudate nucleus of the basal ganglia.

A mother brings her 17 year old daughter to the ED for having a seizure during dinner. The patient is confused but remembers having "deja vu" at the dinner table but otherwise does not recall the event. Her mother reports that during the seizure, her daughter started smacking her lips and then "passed out". A. Absence Seizure B. Simple Partial Seizure C. Complex Partial Seizure D. Tonic/Clonic Seizure

Complex Partial Seizure

65-y/o man with h/o carotid atherosclerosis presents with aphasia and right-sided weakness; PE: dense right-hemiparesis, positive Babinski on right; W/U: CT shows left middle cerebral artery (MCA) territory infarction and edema.

CVA

A 51-year-old man with no significant past medical history comes to the office complaining of difficulty walking x3 days. He initially felt weak in both feet, but now the weakness has spread across both lower legs. He also states that he got food poisoning after eating some sketchy chicken last week. His labs show elevated albumin in his CSF. Which of the following organisms was this patient likely infected with prior to his difficulty walking? a. Campylobacter jejuni b. Klebsiella pneumoniae c. E. Coli d. D. Salmonella

Campylobacter jejuni

A 54-year old man comes to urgent care with a resting tremor. He has developed a shuffling gait. Additionally, he has been having trouble sleeping for the past year. He has no history of intravenous drug use or recent travel. He is diagnosed with Parkinson's disease and started on levodopa, a synthetic dopamine precursor. Which of the following is the best additional management for this patient? A. Ropinirole B. Entacapone C. Benztropine D. Carbidopa E. Selegiline

Carbidopa In the treatment of Parkinson's disease, carbidopa is almost always co-prescribed with levodopa to prevent its metabolism into dopamine outside of the CNS. This leads to increased drug action in the brain as well as greatly reduced side effects, particularly gastrointestinal.

__________________________ has been established as the treatment of choice in patients with a documented TIA and a tightly stenotic lesion greater than 70%

Carotid endarterectomy

In a patient with amaurosis fugax what is the most appropriate initial diagnostic study? A. Ophthalmoscopy B. Schiotz tonometry C. MR angiography D. Carotid ultrasound

Carotid ultrasound The most common cause of amaurosis fugax is an atherosclerotic plaque in the carotid artery which can be identified with ultrasound.

65-y/o woman with h/o spinal metastases from breast cancer presents with pain radiating down the back of her leg, saddle anesthesia, urinary retention; PE: absent ankle jerk reflexes; W/U: CT shows large bony fragment in lumbar spinal canal.

Cauda Equina Syndrome

A 52-year-old man comes to the clinic because of gradual cognitive decline. His 25-year-old daughter says, "he's changed these past few months. He is now very forgetful and is frequently agitated, which is not like the old him." He has a family history of cardiovascular disease, and his mother died due to rupture of an abdominal aortic aneurysm. He is diagnosed with Huntington disease. Which of the following most accurately describes this condition? A. Autosomal recessive inheritance pattern B. Central nervous system CREB binding protein abnormalities C. The Purkinje cells of the cerebellum and the lateral tuberal nuclei of the thalamus are the areas damaged D. The midbrain and pons are the areas primarily affected E. X-linked recessive inheritance pattern

Central nervous system CREB binding protein abnormalities Huntington disease involves a mutation of the Huntingtin gene. It is characterized by cognitive impairment, chorea, and changes in mood. Excessive glutamine attaches to the Htt protein, causing dislocation of CREB binding protein (CBP) away from its normal location near the nucleus, which is responsible for the gradual neuronal death in Huntington disease.

A 61-year-old man is sitting down the cardiology clinic waiting room when he falls to the left side of the chair onto the floor. He did not hit his head with the fall, but continues to have leg weakness. He has a DM type 2, and had a myocardial infarction two years ago. His medications include metformin, atorvastatin, lisinopril and aspirin. On physical examination his vitals are within normal limits, he is alert and oriented, and there is profound weakness and absent sensation of his entire left leg. He is taken to the emergency department for further management in consultation with neurology. Glucose level is 103 mg/dL, and a non-contrast head CT is negative for intracranial bleeding. What is the next best step in management? A. Serial neurologic exams every 2 hours B. Administer tissue plasminogen activator (tPA) C. Order MRI/MRA and diffusion weighted MRI to confirm diagnosis D. Consult neurosurgery for embolization of suspected ruptured aneurysm. E. Administer Morphine, Oxygen, Nitrates, and Aspirin

Cerebral infarction is a type of ischemic stroke caused by blockage of the cerebral arteries. Tissue plasminogen activator (tPA) may be used to dissolve a clot in the acute (<3 hours from onset) setting of ischemic stroke. This patient's presentation is highly concerning for an ischemic stroke (or cerebral infarction) in the anterior cerebral artery (ACA) which covers the motor and sensory to lower limbs. Ischemic strokes are due to blockage of cerebral vessels by three main mechanisms: thrombus formation, embolism, or global hypoxia.

A 74-year-old man is brought to the emergency department because of an acute onset of left arm paralysis and expressive aphasia. Medical history is significant for hypertension, coronary artery disease, hypercholesterolemia, and atrial fibrillation. Neurological examination shows left arm strength 2/5, hyperreflexia on the bicipital reflex, and intact sensation for temperature and pain. The patient's CT is shown. Which of the following is the most likely diagnosis? A. Brain tumor B. Cerebrovascular accident C. Epileptic seizure D. Sepsis E. Subarachnoid hemorrhage

Cerebrovascular accident is characterized by sudden onset of weakness, facial droop, or difficulty talking. On a CT scan, the area affected by the stroke is represented by a hypodense region of vasogenic edema with or without surrounding sulcal effacement and an hyperdense, occluded artery leading to the affected area.

Irregular, spasmodic, random and non-rhythmic involuntary movements of limbs or facial features Tic Tremor Chorea Dystonia Dyskinesia

Choria

75-y/o alcoholic man on warfarin for h/o atrial fibrillation presents with declining mental status, headache, and papilledema; CT shows crescenteric, hypodense, 2 cm fluid collection along convexity.

Chronic Subdural Hematoma

A 60 y/o Asian male presents to the ED complaining of a sudden severe headache, nausea, and dizziness that occurred as he was having some drinks at a local bar. He has a PMI of alcohol abuse and used to be an avid cocaine user. The patient is A&Ox 3, w/ a BP of 158/92, However his pupils are unequal in size and are responding inappropriately to light stimulation. CT imaging suggests no masses but a finding of blood localized within the brain tissue. Which of the following is the most likely cause of this patients headache? a. Epidural hematoma b. Chronic subdural hematoma c. Intraparenchymal Hemorrhage d. Ruptured cerebral aneurysm

Chronic subdural hematoma

A 40-year-old man with a history of alcohol abuse is brought to the emergency department by police, who found him lying down by the side of the street. On examination he is somnolent and confused. He has a horizontal gaze palsy with impaired vestibulo-ocular reflexes and severe truncal ataxia in the presence of normal motor strength and muscle stretch reflexes.

Wernicke Encephalopathy

A 44-year-old male smoker presents with a 9-year history of recurrent headaches. Headaches occurred twice-monthly initially, always in the early hours of the morning (2 a.m. to 3 a.m.). The headaches have increased to an average of 2 episodes per day. The acute episodes can occur at any time, and last between 2 and 4 hours. He always has a nocturnal event. Attacks are triggered immediately after drinking alcohol or with the smell of strong aftershave or gasoline. The pain is excruciating and focused around his right eye. The right eye reddens and tears, the right eyelid droops, and the right nostril runs. He becomes severely agitated during attacks, often pacing the room or rocking back and forth. Physical exams, lumbar puncture, brain MRI (including pituitary views), and pituitary function blood tests are normal.

Cluster Headache

A 60-year-old woman comes to the emergency department with the complaint of a severe headache, nausea, and sensitivity to light. Past medical history reveals a seizure disorder secondary to a left temporal A-V malformation. Soon after arriving to the emergency department, the patient develops loss of consciousness requiring endotracheal intubation. Vital signs reveal a blood pressure of 185/90 mm Hg. Which of the following is the most appropriate initial study to support the diagnosis for this patient? A. Magnetic resonance angiography of the head and neck B. Cerebral angiography C. Computed tomography of the head with contrast D. Computed tomography of head without contrast E. Magnetic resonance imagine of the head

Computed tomography of head without contrast An intracranial hemorrhage is simply bleeding within the skull. There are many causes of intracranial bleeding, including physical trauma or rupture aneurysm. Anticoagulant therapy and disorders with blood clotting increase the risk for intracranial hemorrhages. These hemorrhages are classified into two groups, intra-axial and extra-axial. This patient is suffering from a subarachnoid hemorrhage, or bleeding into the subarachnoid space. The initial study of choice in patients suspected of having a subarachnoid hematoma is computed tomography of the head without contrast. Once hemorrhage is identified by computed tomography, cerebral angiography should then be performed. If cerebral angiography is found to be negative, the next step is to perform an magnetic resonance of the head.

Neuro Vignettes An infant boy is brought to the emergency department due to lethargy and enlarging head circumference. The parents deny any recent infections or trauma to the patient. They report he had 2 episodes of emesis and is inconsolable. On physican exam, head circumference is larger than expected. An MRI of the head is performed, which shows aqueductal funnelling and enlargment of the lateral and third ventricles.

Congenital aqueductal stenosis

A 32-year-old woman is brought to your office by her husband. The husband says that she had been acting strange lately. She has been forgetful, and she sometimes becomes angered for no reason, which is highly unusual for her. She has also been having random, uncontrollable movements, which are also new. On examination, she appears withdrawn and flat. On further questioning, she reveals that her father died at age 45 from a movement disorder. Which of the following is the pathological hallmark of the patient's condition?

Huntington's disease is a progressive neurodegenerative disorder characterized by loss of neurons in the caudate nucleus and putamen.

A 50-y/o with h/o alcoholism presents with psychosis, opthalmoplegia, and ataxia; MRI: mamillary body atrophy and diffuse cortical atrophy

Wernicke Encephalopathy

A 53-year-old man is brought by his daughter to the clinic. She lives a town away but visits often. She reports that on recent visits, his mood has been volatile, ranging from aggressive at some moments to depressed at others. She has noticed some new jerky movements which she has never seen before and has been quite forgetful. She is concerned that he might be abusing alcohol and drugs. What changes would you expect in the brain of this patient? Increased norepinephrine at the locus ceruleus Increased acetylcholine at the caudate Decreased seratonin at the raphe nucleus Decreased GABA at the caudate Increased dopamine at the ventral tegmentum and substantia nigra pars compacta

Decreased GABA at the caudate The patient presents with signs and symptoms of Huntington's disease. This condition is marked by a decrease in GABA at the caudate nucleus.

35 y/o female runner mentions she has over the past couple months she has been experiencing pins and needs to her legs that only lasts for a couple hours. When this happens she is fatigued, and has an uncoordinated gait. You order an head CT which is inconclusive, her MRI shows white matter lesions, and her LP has elevated IgG. What would you prescribe for this patient? A. Corticosteroids and Diazepam B. Anticholinergics C. Levodopa D. Corticosteroid and Anticholinergic

Corticosteroids and Diazepam

32 y/o HIV + M who has a pigeon keeping neighbor p/w headache, fever, mild nuchal rigidity, and papilledema Imaging: scattered focal lesions; LP: CSF with lymphocytic pleocytosis; India ink shows round yeast like cells

Cryptococcal Meningitis

50 y/o F p/w tonic clonic seizure, headache, vomiting, vision blurring, papilledema MR/CT, head: Multiple ring enhancing lesions

Cysticercosis

__________________ is a surgical therapy for Parkinson disease that alters nerve firing in such a way to mimic a temporary lesion in the globus pallidus interna and substantia nigra.

Deep brain stimulation

A patient presents with a daily headache which has worsened over the past several months. On funduscopic examination, you notice that the optic disk edge is indistinct and the veins do not pulsate. There is an increased pressure in subarachnoid space along the optic nerve. What can possibly cause this? A) Glaucoma B) Migraine C) Visual acuity problem D) Increased intracranial pressure

Increased intracranial pressure

A 26-year-old man who presents to the ED with sudden left side motor weakness which occurred during class. He also complains of headache, chronic fatigue, and excessive daytime sleepiness. Blood pressure (BP) was reported to be 197/145 mm Hg in the admission examination, but the patient had no history of taking medication for HTN. What is the most likely diagnosis? A. Thrombotic Stroke B. Embolic Stroke C. Subararchnoid Hemorrhage D. Intracerebral Hemorrhage

Intracerebral Hemorrhage

An abrupt onset of a focal neurologic deficit that worsens steadily over 30 to 90 minutes, altered level of consciousness, stupor, or coma. Headache, vomiting and signs of increased ICP. What is the most likely diagnosis? A. Thrombotic Stroke B. Embolic Stroke C. Subararchnoid Hemorrhage D. Intracerebral Hemorrhage

Intracerebral Hemorrhage

A 58-year-old violinist presents to the urgent care clinic with a tremor that has made it nearly impossible for him to play his music. After further questioning and a physical exam, the patient is diagnosed. He undergoes a deep brain stimulation to alleviate the tremor. Which of the following best describes the original pathology present in the patient? A. Proteins which have abnormal number of glutamine residues B. Degeneration of the nigrostriatal dopaminergic neurons C. Oligodendrocyte damage D. Accumulation of blood in the basal ganglia E. Cytoplasmic accumulations of tau proteins

Degeneration of the nigrostriatal dopaminergic neurons

A 78-year-old woman presents with confusion, agitation, and visual hallucinations. She has become progressively confused over the past 2 years and has had trouble managing her affairs, including shopping and paying bills. It is unclear when her confusion started. Initially, she was having trouble following conversations and got lost on several occasions. Her memory, which was previously good, has begun to deteriorate. At night, she sees children playing in her house and has called the police on several occasions. She gets angry easily and has been paranoid about her relatives and their intentions. Her behavior tends to fluctuate from day to day. She started to shuffle about 6 months ago and had difficulty getting out of chairs, and getting dressed to go out seemed to take hours. On one occasion, she fell and was taken to the emergency department but was subsequently discharged with no diagnosis given.

Dementia with Lewy body

what is the EEG finding and what treatment would you provide for a patient who is STATUS epilepticus? A. EEG - 3Hz spike waves; tx - Ethosuximide (Zarontin) B. EEG - focal discharges; tx - IV Levetiracetam C. EEG - normal; IV Benzodiazepines D. EEG - focal discharges; immediate surgical resection of seizure focus E. EEG - generalized spike and wave patterns; Lamotrigine (Lamictal)

EEG - 3Hz spike waves; tx - Ethosuximide (Zarontin)

A 65-year-old man comes to the emergency department because of a sudden onset of aphasia and dysarthria for the past four hours. He has since developed left-sided hemiplegia. Patient's medical history is significant for hypercholesterolemia, hypertension, and diabetes mellitus type 2. Physical examination shows spastic hemiplegia with hyperreflexia on deep tendon reflexes in the left upper and lower extremities. CT scan without contrast shows no abnormalities. Which of the following imaging modalities would most likely detect a diffusion restriction within the brain at the earliest stage? CT perfusion Diffusion weighted MRI GRE/SWI T1 MRI T2 MRI

Diffusion weighted MRI (DW-MRI) is the imaging modality that detects ischemic stroke at the earliest, minutes within the initiation of the infarct.

37-y/o man with family history (FH) of a father who died at 45 with worsening tremor and dementia presents with poor memory, depression, choreiform movements, and hypotonia; W/U: MRI demonstrates marked atrophy of the caudate nucleus.

Dopamine agonists (bromocriptine) are first line treatment for early disease Levodopa/carbidopa are mainstays of therapy Selegiline (an MAO-B inhibitor) may be neuroprotective and may decrease the need for levodopa Catechol-O-methyltransferase inhibitors increase the availability of levodopa to the brain and may decrease motor fluctuations If medical therapy fails, attempt surgical pallidotomy or chronic deep brain stimulation

30-y/o presents with loss of libido, galactorrhea, and irregular menses; PE: bitemporal hemianopia; W/U: negative beta human chorionic gonadotropin (β-hCG).

Dopamine agonists: Cabergoline, bromocriptine, or pergolide Surgery: Should be considered when medical tx has failed or in the presence of visual field defects

A 74 y/o man comes in for his annual physical with a PMH of DM and HTN. You notice that he shuffled his way into the exam room and sat hunched over in the chair. During the exam, you also notice extremely shaky hands at rest, but when he reached over to pick up his glasses, his hands appeared to become more steady. You also notice that his arms appeared rigid while reaching over for his glasses. What is the most likely cause of his symptoms? A. ACh deficiency B. Serotonin deficiency C. Dopamine deficiency D. Oxytocin deficiency

Dopamine deficiency

A 40-year-old male with Down syndrome is brought to your clinic by his mother. She reports that over the past few months he has started having difficulty managing his daily routine at his assisted-living facility and no longer seems like himself. She says that last week he wandered away from the facility and was brought back by police. Additionally, he has stopped taking his regular antiepileptic medication, and she is concerned that he might have a seizure. TSH is checked and is normal. Which of the following is most likely to be responsible for this man's current presentation?

Down syndrome occurs due to trisomy of chromosome 21, which also encodes the beta-amyloid precursor protein. Alzheimer disease occurs at an earlier age in patients with Down syndrome due to abnormal metabolism and accumulation of beta-amyloid protein in amyloid plaques.

40 yo F presents with numbness, lower extremity weakness, and difficulty walking. She reports having had a URI approximately two weeks ago. She says that her weakness started from her lower limbs to her hip and then progressed to her upper limbs. She also complains of lightheadedness on standing and shortness of breath VS: Afebrile, P 115, BP 130/80 with orthostatic changes, RR 16 Gen: NAD Lungs: WNL CV: WNL Ext: WNL Neuro: Loss of motor strength in lower limbs; absent DTRs in patella and Achilles tendon; sensation intact

IVIG or plasmapheresis as soon as possible Measure vital capacity and maximum inspiratory force to monitor for respiratory compromise Watch for autonomic instability including hypotension, temperature dysregulation, and cardiac arrhythmias

Impairment/distortion of voluntary movements resulting in fragmented or jerking motions Tic Tremor Chorea Dystonia Dyskinesia

Dyskinesia

Disturbance of power to control the range of movement in muscle action Agnosia Athetosis Agraphia Dysmetria Dyskinesia

Dysmetria

A 40-year-old man presents with a history of neck stiffness and limited head mobility with the tendency for his head to turn to the right and tilt to the left. He has also developed increasing neck discomfort and an irregular tremor of the head. After worsening over 1 year, the symptoms have stabilized but persisted. He reports that the abnormal head positioning, pain, and tremor are partially relieved if he gently touches his left cheek with his hand. No other family members are affected.

Dystonia

Movement characterized by sustained muscle contraction resulting in muscle spasm and abnormal posture Tic Tremor Chorea Dystonia Dyskinesia

Dystonia

40-y/o with h/o Campylobacter enteritis 1 week ago presents with ascending symmetric muscle weakness; CSF shows ↑ protein, normal cellularity (albuminocytologic dissociation).

IVIG or plasmapheresis as soon as possible Measure vital capacity and maximum inspiratory force to monitor for respiratory compromise Watch for autonomic instability including hypotension, temperature dysregulation, and cardiac arrhythmias

A 18 y.o patient was eating some french fries with his friends when all of a sudden the patient slouches over. The patient then begins shaking uncontrollably all over his body. His friends quickly call 911 and he is sent to the hospital. Throughout the short ambulance ride, the patient would slowly come to, but then all of a sudden would return to shaking. This happened 5 times on the way to hospital and he is slowly regaining consciousness on the way in. You are the emergency PA on staff. What EEG finding would you most likely find based on the symptoms and what treatment would you provide? A. EEG shows 3Hz spike waves; Ethosuximide (Zarontin) B. EEG shows focal discharges; IV Levetiracetam C. EEG is normal; IV Benzodiazepines D. EEG shows focal discharges; immediate surgical resection of seizure focus E. EEG shows generalized spike and wave patterns; Lamotrigine (Lamictal)

EEG is normal; IV Benzodiazepines

What would the EEG show and what treatment do you provide for absence seizures? A. EEG shows 3Hz spike waves; Ethosuximide (Zarontin) B. EEG shows focal discharges; IV Levetiracetam C. EEG is normal; IV Benzodiazepines D. EEG shows focal discharges; immediate surgical resection of seizure focus E. EEG shows generalized spike and wave patterns; Lamotrigine (Lamictal)

EEG shows 3Hz spike waves; Ethosuximide (Zarontin)

________________ is obtained in all patients with acute ischemic stroke in whom cardiogenic embolism is suspected.

Echocardiography

A 7-year-old boy comes to the emergency department because he has been experiencing several staring episodes during which he was unresponsive to those around him. These episodes are often accompanied by lip smacking. After the episodes the boy continues on with his daily activities, and does not realize he has suffered an unresponsive episode. Which of the following is the primary diagnostic test for this patient's disorder? A. Electroencephalogram B. Echocardiogram C. MRI D. Cardiac stress test

Electroencephalogram

A 30 y/o woman comes to the office because of intermittent blurry vision in her right eye for the past 3 years. She says these episodes usually last a few weeks, and then completely resolve. At other times, she has noticed blurring of the vision in her left eye, and pain while moving her affected eyes. She has also experienced difficulty in maintaining balance while walking, as well as urinary urgency. Which of the following is most likely to be found during further investigations? A. Elevated intracranial pressure B. Elevated hemoglobin A1C C. Atrophy of the cerebral cortex D. Death of upper and lower neurons E. Elevated IgG in CSF

Elevated IgG in CSF

(Thrombotic /Embolic) are caused by a blood clot or plaque debris that develops elsewhere in the body and then travels to one of the blood vessels in the brain through the bloodstream.

Embolic

(Thrombotic/Embolic) stroke is a type of ischemic stroke that involves obstruction of a vessel with a foreign body from another part of the body.

Embolic

A 19-year-old man presents to the ER with a witnessed generalized tonic-clonic seizure episode. One month previously he had an upper respiratory tract infection. Over the last 2 weeks he developed headaches, blurred vision, generalized weakness, and progressive difficulty walking. Examination revealed pain on eye movement as well as limb and gait ataxia.

Encephalitis

A 42-year-old male presentswith confusion, headache, and fever. The patient is unable to answer questions. A head CT is negative for a space-occupying lesion or hemorrhage. An MRI is shown. A lumbar puncture is performed, with cerebral spinal fluid (CSF) analysis showing a lymphocytic pleocytosis and normal glucose. PCR of the CSF is positive for HSV-1.

Encephalitis

A 56-year-old man presents to the ER with headache, fever, blurred vision, and somnolence followed shortly by unresponsiveness to verbal commands. For the last 2 weeks he had been feeling ill, and had decreased appetite and myalgias. Three days prior to presentation he experienced intermittent confusion, severe headache, and fever. Examination was limited by a generalized tonic-clonic seizure, for which he received lorazepam.

Encephalitis

A 65-year-old man is brought to urgent care because of a history of worsening balance and shuffling gait. He has been having difficulty rising from a chair, and constipation. There is a tremor in his right hand that resolves when he reaches for something. There is no family history of movement disorders. He is started on appropriate therapy, but passes away 6 years later of related causes. Which of the following is the most likely finding on autopsy? A. Amyloid neuritic plaques in neocortex B. Atypical lymphocytes C. Eosinophilic sphere-shaped inclusions in cytoplasm D. Neurofibrillary tangles within neurons E. Protein aggregations and intranuclear inclusions

Eosinophilic sphere-shaped inclusions in cytoplasm Parkinson's disease can be diagnosed on autopsy by the presence of Lewy bodies, which are small hyaline inclusion bodies. Parkinson's disease is a movement disorder caused by the loss of dopaminergic neurons in the substantia nigra.

20-y/o presents with nausea, vomiting, and headache 2 hours after being hit in the temple with a baseball; patient lost consciousness initially but recovered quickly; W/U: CT shows lens-shaped, right-sided hyperdense mass adjacent to temporal bone

Epidural Hematoma

A 15 y/o male is brought into the ED for skateboarding straight into a wall with no helmet. While receiving report from the first responders who brought him in, they mention the patient was unconscious when they arrived but is awake now. They also mention that the patient has a skull fracture on the right side of his head, and while en route to the hospital they observed a blown right pupil. Since you're a superstar, you ordered a CT of his head upon arrival. What do you suspect is going on with this patient? His CT can be found below: A. Subarachnoid Hemorrhage B. Intracranial Hemorrhage (ICH) C. Subdural Hematoma D. Epidural Hematoma

Epidural Hematoma

An 8 year old boy is brought to the ED by his mother because he fell off the swingset in the backyard. His little sister was screaming for their mother because her brother was "asleep" after landing on his head. By the time their mother got out there, the boy was awake and walking around but was confused about what happened. His GCS is 7 upon arrival and his pupils are dilated. A head CT is ordered. Which of the following do you expect to be his diagnosis? A. Acute Subdural Hematoma B. Chronic Subdural Hematoma C. Epidural Hematoma D. Intraparenchymal Hemorrhage

Epidural Hematoma

Emily, a 35 y/o F, was skiing when she crashed into a tree and passed out briefly. When she woke up she insisted she was fine to her husband. She only has a few scrapes & bruises. Her husband would not be persuaded by Emily and took her to the ER. The PA did a CT scan w/out contrast and saw a biconvex deformity on the image. What should the PA begin treatment for? A. Stroke B. Epidural Hematoma C. Acute Subdural Hematoma D. Ruptured Aneurysm

Epidural Hematoma

25 yo F with no significant past medical history is brought to the ER after having been found unresponsive with an empty bottle lying next to her VS: T 38°C (99.8°F), P 50, BP 110/50, RR 9, O2 sat 92% room air Gen: Drowsy HEENT: Pinpoint pupils Lungs: WNL CV: Bradycardia Abd: WNL Ext: WNL Neuro: Opens eyes to painful stimuli Limited PE with ABCs

Narcotic Overdose

A middle-aged man is transported to the emergency department unconscious and accompanied by a nurse from the medical floor. The nurse states that the patient was in line in front of her in the hospital cafeteria when he suddenly fell to the floor. He then had a "generalized tonic-clonic seizure." She called for assistance and accompanied him to the emergency department. No other historical information is available. On physical examination, the patient is confused and unresponsive to commands. He is breathing adequately and has oxygen in place via nasal prongs. His vital signs are as follows: temperature, 38°C; blood pressure, 170/90 mm Hg; heart rate, 105 bpm; respiratory rate, 18/min. Oxygen saturation is 99% on 2 L of oxygen. Neurologic examination is notable for reactive pupils of 3 mm, intact gag reflex, decreased movement of the left side of the body, and Babinski reflexes bilaterally. Examination is otherwise unremarkable.

Epilepsy

A 68-year-old woman presents with a complaint of "shaking hands." She reports a 10-year history of bilateral hand tremor that has slowly progressed and is worse in her right hand. It mainly bothers her when she is using her hands for various tasks. She has great difficulty drinking from cups and eating peas and other foods, and uses either a straw or both hands to eat and drink. She also finds writing and signing checks problematic. She has come to rely increasingly on her spouse for assistance with activities of daily living, and has retired from work as a secretary. She has stopped eating out in restaurants because of the social embarrassment. She denies any slowness of movement, rigidity, or cramping. Her father has a long history of tremor, but otherwise she has no personal or family history of neurologic diseases. When the patient has a glass of red wine, she notes that her tremor abates.

Essential Tremor

25 y/o female presents to your clinic complaining of involuntary movement of her hands when taking notes in class or typing her sneakers. She is a PA student and has been feeling a lot of anxiety lately. For the past two weeks, she noticed no involuntary movements after having drinks with her friends. PE shows no other significant neurological findings. What is your diagnosis and treatment? A.Multiple Sclerosis: Acetazolamide B. Essential tremor: treatment not usually needed C. Parkinson: Plasmapheresis D. Essential tremor: Levodopa-carbidopa

Essential tremor: treatment not usually needed

A 9-year-old boy is performing poorly in school. His teacher is frustrated because he is frequently seen "staring off into space" and not paying attention. You suspect a seizure, what would you give this boy as the most effective first line of treatment management? A) No treatment B) Lamotrigine C) Acetylcholinesterase inhibitors/Pyridostigmine D) Ethosuximide

Ethosuximide

The student in the prior question is brought to a neurologist by his mother, based on a referral from his PCP. Imaging and lab studies are completed, which are found to be normal. An EEG is done on the student, which shows 3-Hz spike-and-wave discharge complexes. What would be the first line treatment for this patient? a. Ethosuximide (Zarontin) b. Lamotrigine (Lamictal) c. Treatment is not needed at this time. It would be best to continue monitoring the student's symptoms. d. Surgery is needed.

Ethosuximide (Zarontin)

A 10-month-old girl is brought to the emergency department with a history of recurrent right arm and leg jerking followed by prolonged sleepiness. The parents report a 2-day history of fever with chest congestion and irritability. The child is admitted to the hospital for neurologic evaluation.

Febrile Seizure

A previously healthy and developmentally normal 18-month-old boy presents to the emergency department by ambulance after his parents witnessed a seizure. The parents report the boy had a febrile illness with mild upper respiratory symptoms and they treated him with acetaminophen and ibuprofen at home. The child then began to have frequent jerking movements of all limbs. The rectal temperature was 103.1°F (39.5°C). The parents called 911, and an acetaminophen suppository was administered during transport to the emergency department. The jerking stopped after approximately 5 minutes. Afterward, the child was sleepy but responsive to verbal stimulation. Examination revealed a diffuse erythematous maculopapular rash and a normal mental and neurologic status.

Febrile Seizure

Which of the following findings is characteristic of lower motor neuron deficit? a. Hyperreflexia b. Clasp knife rigidity c. Dysdiadochokinesis d. Flaccid paralysis e. Sensory loss

Flaccid paralysis

A 70-year-old man presents with a generalized tonic-clonic seizure. His wife states that during the past month there have been times when he does not respond, mumbles words that do not make sense, and stares. After several minutes, he is usually responsive. His past medical history includes hypertension and hypercholesterolemia. He had a stroke during the preceding year. Although he recovered significantly, he still walks with a limp on the left side.

Focal (Partial) Seizure

An 18-year-old girl presents with several episodes of confusion over the past several months. Typically, she experiences a warning signal, which she describes as a rising sensation within her abdomen that travels upward through her chest. She is usually unaware for a few minutes, but others have told her that she smacks her lips, picks at her clothing, and is unable to speak during these episodes. After the event, she feels tired, has a headache, and prefers to lie down. She notes that her memory has not been as good as it was in the past, and her school grades have declined. Her past medical history is notable for several febrile seizures as a young child, although she was not treated for seizures at that time. An aunt was diagnosed with seizures many years ago.

Focal (Partial) Seizure

40-day-old M is brought to the ER because of irritability and lethargy, vomiting, and ↓ oral intake of three days' duration. Today his parents noted that he had a fever of 101.5°F, and he subsequently had a seizure. The baby's weight at delivery was 2500 grams, and he has been well. VS: T 39°C (102°F), P 160, BP 77/50, RR 40, O2 sat 92% room air Gen: Irritable infant Lungs: Clear CV: Tachycardia; I/VI systolic murmur Abd: WNL Neuro/psych: Bulging fontanelle, ↓ responsiveness

Fulminant presentation (< 24 hours) or ill-appearing patients: Give antibiotics within 30 minutes; give dexamethasone along with or prior to antibiotics. Then perform a history and physical and obtain a CT/MRI (if indicated) and LP. Subacute course and stable patients: Obtain a history and physical and obtain a CT/MRI (if indicated), blood cultures, and LP; then give empiric treatment. Obtain a head CT/MRI before LP if a mass lesion is suspected

A 35-year-old man originally from sub-Saharan Africa presents with a 3-week history of headache and fever. On questioning, he has had intermittent diarrhea and weight loss of 10 kg over the last year. The patient's Glasgow Coma Scale score is 15, he is hemodynamically stable, and the only positive findings on examination are a fever of 100.4°F (38.5°C) and oral candidiasis

Fungal Meningitis

1. A 16-year-old boy presents to the emergency department with a first-time seizure event after attending an all-night party and consuming alcohol. Witnesses described the seizure as beginning abruptly with bilateral limb stiffening, followed by jerking movements in all limbs; the patient has no memory of warning symptoms prior to the seizure. The event seemed to last about 1 minute, and the patient was quite somnolent afterward. Further review of the history reveals that the patient has been experiencing "jerks" in the morning after awakening, usually involving the arms and shoulders and occasionally causing him to drop things. These "jerks" do not seem to present a problem during the rest of the day.

Generalized Seizure

A 55-year-old woman recently diagnosed with a brain tumor in the left hemisphere has a witnessed seizure event. The seizure is initially recognized when the patient begins staring and is unresponsive to those around her. She seems to be picking at her clothes with her left hand, but the right arm and leg are not moving. After 20 seconds, she displays rapid head-turning and eye deviation to the right, with tonic extension of the right arm and flexion of the left arm. This is quickly followed by tonic extension of the left arm as well, then clonic jerking occurring in both arms synchronously. This jerking gradually slows and stops after about 30 seconds. The patient then becomes quite somnolent, and she appears to be using her arm and leg less on the right than the left.

Generalized Seizure

A 16 y/o autistic girl was standing in the living room with her family. All of a sudden she drops to the floor losing consciousness. Her brother noticed her extremities stiffen and her legs and arms starts to jerk erratically. She was in this state for 2 minutes, afterwards it stopped and she went into a deep sleep. If this patient had an EEG on her while she had a seizure what type of wave patterns would you expect? A. 3hz spike wave pattern B. Focal discharges near the focus C. Generalized spike waves D. Alpha waves

Generalized spike waves

A 50-yr-old pt comes to your office complaining of new jerky movements that he cannot control. In your history you find he has some recent depression and has been forgetful. He mentions that his grandfather had something like this but never knew his diagnosis. What test would you do to help you definitively determine your dx? A. MRI B. Genetic testing C. Blood test D. Nerve conduction study

Genetic testing

65 yo F presents with a severe intermittent headache in the right temporal lobe together with blurred vision in her right eye and pain in her jaw during mastication. VS: T 37°C (99°F), P 85, BP 140/ 85, RR 18, O2 sat 100% room air Gen: NAD HEENT: Tenderness on temporal artery palpation Neck: No rigidity Lungs: WNL CV: WNL Abd: WNL Ext: WNL Neuro: WNL

Giant Cell Arteritis

A 54 yo male smoker presents with vague headaches with associated vomiting that awakens him from sleep occasionally or occurs when waking up. This has been happening for about 2 weeks. The headache usually resolves about an hour into his morning routine. The patient is afebrile. What is the cause of this patient headaches? A. Cluster headaches B. Migraines C. Glioblastoma D. Giant Cell Arteritis

Glioblastoma

A 52-year-old man comes to the clinic because of severe headaches that are worse in the morning and not relieved by over the counter painkillers for the past several months. His colleagues also report he has been more forgetful and has had increasing difficulty concentrating and completing tasks at work. Physical examination shows that he is afebrile and has no vision changes or nuchal rigidity. Neuro exam is unremarkable. CT imaging of his head shows a large heterogeneous right hemispheric mass. Magnetic resonance imaging with and without contrast shows a heterogeneous enhancing lesion in the right temporal lobe with hypodensities suggested central necrosis. What is the most likely diagnosis? A) Glioblastoma Multiforme B) Meningioma C) Meningitis D) Pseudotumor cerebri

Glioblastoma Multiforme

A 38-year-old man comes to the clinic because of increasingly erratic behavior. His wife brought him in and says, "he has had terrible mood swings and makes these strange movements almost like he's trying to dance." He works as a musician but his wife has made him stay home for the past month due to his condition. Upon further questioning the patient reveals he is also having difficulty playing the guitar because he feels like he cannot always control his movements. He tells you his mother was institutionalized when she was 50 for similar behavior and his grandfather was "drowned for being crazy." Which of the following abnormalities is most likely present in this patient's brain? A. Accumulation of copper in the basal ganglia. B. Areas of low pigmentation in the substantia nigra. C. Diffuse cortical atrophy D. Hemorrhage within the lateral ventricles E. Gliosis on the caudate and putamen.

Gliosis on the caudate and putamen.

A 72-year-old female is brought in by ambulance after being found down in her home. Her daughter discovered her after returning from work and does not know how long she has been down. Physical exam reveals right sided paralysis with a positive babinski sign. She is also found to produce strained stuttering speech with no perceivable meaning. She is unable to follow any instructions and cannot repeat speech. An MRI is obtained showing a left MCA infarct.

Global Aphasia

32 y/o male presents with severe, stabbing, unilateral pain from the throat to the ear. Patient does not display any motor or sensory deficit, but says pain spikes during swallowing, chewing and similar motions. What would be the diagnosis and treatment? a. Trigeminal nerve (CN -V) palsy- anticonvulsants (phenytoin/ gabapentin) + antidepressants (amitriptyline/ duloxetine) b. Glossopharyngeal nerve (CN - IX) palsy - anticonvulsants (phenytoin/ gabapentin) + antidepressants (amitriptyline/ duloxetine) c. Facial nerve (CN - VII) palsy - steroids, physical therapy d. Hypoglossal nerve (CN - XII) palsy -steroids, physical therapy

Glossopharyngeal nerve (CN - IX) palsy - anticonvulsants (phenytoin/ gabapentin) + antidepressants (amitriptyline/ duloxetine)

24 yo M is brought to the ER in a drowsy state. His wife reports that he was working at home when he suddenly stiffened, fell backward, and lost consciousness. While he was lying on the ground, he was noted to have no respiration for about one minute, followed by jerking of all four limbs for about five minutes. He was unconscious for another five minutes. VS: T 37°C (98.2°F), P 90, BP 120/80, RR 12 Gen: NAD Lungs: WNL CV: WNL Abd: WNL Ext: WNL Neuro: In a state of confusion and lethargy but oriented; no focal neurologic deficits

Grand Mal Seizure

A 25-year-old woman is brought into the emergency department (ED) after tripping during a volleyball match. Her teammate notes that she had been stumbling and was starting to have more difficulty with her serve. On arrival, she can no longer raise her legs and labors to adjust herself in bed. She has also begun to complain of shortness of breath. She denies fever but states that 3 weeks ago the entire team suffered from abdominal cramps and diarrhea after a championship cookout. The patient denies previous health problems. On examination, she appears weak and slightly dyspneic. Her temperature is 36.6°C (98°F); heart rate, 50 beats/min; respiration rate, 26 breaths/min; and blood pressure, 90/60 mmHg. Her pupils are sluggish, and she constantly clears her throat. She can only keep her arms up against gravity for 10 seconds, and her hands are limp. She has slight movement of her legs with decreased sensation of pain and fine touch to her knees. Her reflexes are absent. She has no skin lesions. Her heart and lung examinations are unremarkable except for bradycardia and poor inspiratory effort. The abdominal examination reveals normoactive bowel sounds and no masses. Her complete blood count is unremarkable. The pregnancy test is negative. MRI of the brain and spine are normal.

Guillain-Barre syndrome

A 32-year-old man presents to the emergency department with worsening lower extremity weakness. The patient was in his usual state of health until approximately one week prior to presentation, where he developed increased difficulty climbing the stairs. Now he is unable to stand. A few weeks ago he developed bloody diarrhea, which he attributes to drinking unpasteurized milk. On physcal examination, he has bilateral lower extremity 1/5 strength with absent patellar reflexes.

Guillain-Barre syndrome

40 yo F presents with numbness, lower extremity weakness, and difficulty walking. She reports having had a URI approximately two weeks ago. She says that her weakness started from her lower limbs to her hip and then progressed to her upper limbs. She also complains of lightheadedness on standing and shortness of breath VS: Afebrile, P 115, BP 130/80 with orthostatic changes, RR 16 Gen: NAD Lungs: WNL CV: WNL Ext: WNL Neuro: Loss of motor strength in lower limbs; absent DTRs in patella and Achilles tendon; sensation intact

Guillain-Barré Syndrome

40-y/o with h/o Campylobacter enteritis 1 week ago presents with ascending symmetric muscle weakness; CSF shows ↑ protein, normal cellularity (albuminocytologic dissociation).

Guillain-Barré Syndrome

______________ is a dopamine-2 antagonist used to treat movement disorders, hallucinations, and delusions in Huntington disease.

Haloperidol

27 y/o female presented to the ED earlier today experiencing neurological symptoms. She received a CT head where she was diagnosed a primary parietal brain tumor. Which of the following was most likely her presenting "neurological symptom"? a. Personality changes & Urinary incontinence b. Hemianesthesia & receptive aphasia c. Olfactory Hallucinations & behavioral changes d. Gait abnormalities & difficulty concentrating

Hemianesthesia & receptive aphasia

A 70-year-old man with a history of chronic HTN and atrial fibrillation is witnessed by a family member to have nausea, vomiting, and right-sided weakness, as well as difficulty speaking and comprehending language. The symptoms started with only mild slurred speech before progressing over several minutes to severe aphasia and right arm paralysis. The patient is taking warfarin.

Hemorrhagic Stroke

A 25-year-old man presents to the ER after a street fight. His girlfriend reports that he was struck with a bat in the head. After the initial hit, she reported that he briefly lost consciousness but then was normal for several hours. Since then, he has been rapidly decompensating. He is grabbing his head in pain and his mental status is altered. Vital signs are stable. Neurological exam reveals that his right pupil is dilated and his right lid is drooping. If this patient's symptoms are allowed to progress without intervention, which of the following would be expected to occur?

Herniation of the uncus

An 81-year-old woman is brought to the emergency room by her son after witnessing the patient fall and hit her head. The son reports that the patient was in her usual state of health until she complained of chest palpitations. This startled her while she was climbing down the stairs and lead to a fall. Past medical history is significant for hypertension and atrial fibrillation. Medications are lisinopril, metoprolol, and warfarin. Temperature is 99°F (37.2°C), blood pressure is 152/96 mmHg, pulse is 60/min, respirations are 12/min, and pulse oximetry is 98% on room air. On physical examination, she is disoriented and at times difficult to arouse, the left pupil is 6 mm and non-reactive to light, and the right pupil is 2 mm and reactive to light. A right-sided visual field defect is appreciated on visual field testing. There is 1/5 strength on the right upper and lower extremity; as well as 5/5 strength in the left upper and lower extremity. A computerized tomography (CT) scan of the head is shown. Which of the following most likely explains this patient's symptoms?

Herniation of the uncus

65 yo F presents with a severe intermittent headache in the right temporal lobe together with blurred vision in her right eye and pain in her jaw during mastication. VS: T 37°C (99°F), P 85, BP 140/ 85, RR 18, O2 sat 100% room air Gen: NAD HEENT: Tenderness on temporal artery palpation Neck: No rigidity Lungs: WNL CV: WNL Abd: WNL Ext: WNL Neuro: WNL

High Dose Corticosteroids

A 50-y/o with h/o alcoholism presents with psychosis, opthalmoplegia, and ataxia; MRI: mamillary body atrophy and diffuse cortical atrophy

High dose thiamine (up to 500 mg) + glucose

A 72-year-old man with a 5-year history of Parkinson's disease comes to clinic. He is concerned that he is becoming less responsive to levodopa, as he has failed several other medications due to lack of response and/or side effects. He is now experiencing motor fluctuations and dyskinesia that interfere with his activities of daily life and diminish his quality of life. Which of the following is the best surgical treatment option for this patient? A. Lesion of the thalamus B. There is no appropriate surgical treatment C. Excision of the globus pallidus interna D. Excision of the substantia nigra E. High frequency stimulation of the subthalamic nucleus

High frequency stimulation of the subthalamic nucleus Surgical treatment of Parkinson's disease involves deep brain stimulation (DBS). It involves implanting electrodes into the subthalamic nucleus (STN) and providing high frequency stimulation to suppress its neuronal activity, and is reserved for patients who have failed medical therapy.

30-y/o woman with insidious onset of diplopia, scanning speech, paresthesias, and numbness of right upper extremity and urinary incontinence; W/U: MRI shows discrete areas of periventricular demyelination and CSF analysis is positive for oligoclonal bands. (Goal is to reduce paraprotein)

High-dose chemotherapy with autologous stem cell rescue (standard of care, but limited to patients with good functional status). Allogeneic bone marrow transplantation (experimental). Steroid and alkylator combination chemotherapy. Biological molecules (thalidomide, bortezomib)

A 62-year-old patient presents with unprovoked syncope with signs of hypotension. In addition to an ECG and ECHO, what other testing would you do? A. Tilt table B. Holter monitor C. EEG D. MRI

Holter monitor

A 40-year-old man presents to the psychiatry emergency room for inappropriate behavior and confusion. He works as a janitor and has had reasonably good work attendance. His coworkers say that he has appeared "fidgety" for several years. They specifically mention jerky movements that seem to affect his entire body more recently. His mother is alive and well, although his father died at age 28 in an auto accident. On examination, he is alert but easily distracted. His speech is fluent without paraphasias but is noted to be tangential. He has trouble with spelling the word "world" backward and serial seven's, but recalls three objects at 3 minutes. His constructions are good. When he walks, there is a lot of distal hand movement, and his balance is precarious, although he can stand with both feet together. His reflexes are increased bilaterally, and there is bilateral ankle clonus. A urine drug screen is negative.

Huntington

37-y/o man with family history (FH) of a father who died at 45 with worsening tremor and dementia presents with poor memory, depression, choreiform movements, and hypotonia; W/U: MRI demonstrates marked atrophy of the caudate nucleus.

Huntington Disease

A 20-year-old man presents with a two-year history of motor restlessness that has progressed to uncontrollable choreiform movements. He has moderate dementia with a severe gait disturbance as well as agitation and problems with his mood. MRI scan of the brain shows atrophy of the cerebral cortex and caudate nucleus

Huntington Disease

A 42-year-old school teacher presents with difficulty managing her classroom. She has become increasingly irritable with students and fails to complete assigned tasks on time. Her sister and husband report that she has become restless, pays less attention to her appearance and social obligations, and at times is anxious and upset. She has stumbled unexpectedly. Her symptoms resemble those of her mother when she was diagnosed with Huntington disease. On examination, her speech is somewhat uneven and she is inappropriately flippant. Subtracting serial 7s from 100, while seated with her eyes closed, brings out random "piano-playing" movements of the digits along with other movements of the limbs, torso, and face. Subtraction errors occur with this task. She is unable to keep her tongue fully protruded for 10 seconds. Finger tapping is slower than the examiner's, and tapping tempo is uneven. Tandem walking is impaired.

Huntington Disease

____________ presents with choreiform movements, athetosis, aggression, depression, and dementia.

Huntington disease

_________________ is an autosomal dominant movement disorder that involves neurodegeneration via N-methyl-D-aspartate receptor glutamate toxicity.

Huntington disease

Which of the following is the most important modifiable risk factor for ischemic stroke? A. Patent foramen ovale B. Oral contraceptive use C. Sickle cell disease D. Hypertension E. Sickle Cell Disease

Hypertension

30-y/o woman with insidious onset of diplopia, scanning speech, paresthesias, and numbness of right upper extremity and urinary incontinence; W/U: MRI shows discrete areas of periventricular demyelination and CSF analysis is positive for oligoclonal bands. (Goal is to prevent skeletal complications)

IV bisphosphonate if any evidence of skeletal compromise (bony lesions, osteopenia, hypercalcemia). Radiation therapy and/or orthopedic surgery for impending pathologic fractures in weight-bearing bones

25 yo F with no significant past medical history is brought to the ER after having been found unresponsive with an empty bottle lying next to her VS: T 38°C (99.8°F), P 50, BP 110/50, RR 9, O2 sat 92% room air Gen: Drowsy HEENT: Pinpoint pupils Lungs: WNL CV: Bradycardia Abd: WNL Ext: WNL Neuro: Opens eyes to painful stimuli Limited PE with ABCs

IV naloxone Psychiatry consult Suicide preparations

21 yo F presents with a severe headache. She has a history of throbbing left temporal pain that lasts for 2-3 hours. Before these episodes start, she sees flashes of light in her right visual field and feels weakness and numbness on the right side of her body for a few minutes. The headaches are often associated with nausea and vomiting. She has a family history of migraine. VS: T 37°C (99.2°F), P 70, BP 120/80, RR 15, O2 sat 100% room air Gen: NAD Lungs: WNL CV: WNL Abd: WNL Ext: WNL Neuro: WNL

Identify and eliminate triggers. Treat according to severity: Mild: NSAIDs plus an antiemetic such as metoclopramide. Moderate: Abortive (triptans as soon as headache begins). Severe: IV hydration, metoclopramide, dexamethasone, prochlorperazine, or ergotamine. Preventive therapy: TCAs, α-blockers, valproate, β-blockers

30-y/o woman presents with unilateral throbbing headache, nausea, photophobia, scotoma; similar symptoms occur monthly at the same time of her menstrual cycle.

Identify and eliminate triggers. Treat according to severity: Mild: NSAIDs plus an antiemetic such as metoclopramide. Moderate: Abortive (triptans as soon as headache begins). Severe: IV hydration, metoclopramide, dexamethasone, prochlorperazine, or ergotamine. Preventive therapy: TCAs, α-blockers, valproate, β-blockers.

A 29-year-old woman presents with a 3-month history of worsening headaches and increasing visual loss. She describes occasional episodes of bilateral visual grayouts lasting 20 seconds that may be precipitated by bending forward or standing. Over the last 2 weeks she has often heard a "whoosing" sound, synchronous with her pulse, and more noticeable when she is about to go to sleep. Her visual acuity is 20/30 (6/9 meters) in each eye. Fundus examination shows bilateral disk swelling

Idiopathic Intracranial Hypertension

A 75-year-old man comes to the emergency department because of inability to move his right upper and lower extremity after waking from a nap one hour ago. Physical examination shows mild aphasia and left-sided facial droop. A non-contrast head CT scan is obtained and reveals hypo-attenuation within the middle cerebral artery distribution. During physical examination the patient develops a sudden headache, right pin-point pupil and poor gag reflex with increased respiratory effort. Which of the followings is the most appropriate next step in management? A. Administer thrombolytic therapy B. Immediate intubation C. Immediate neurosurgical consultation D. Rapid nitroprusside infusion to reduce blood pressure E. Repeat stat CT scan without contrast

Immediate intubation An ischemic stroke may convert to a hemorrhagic stroke. Any patient with a mental status change and an altered respiratory drive with poor gag reflex requires evaluation of airway, breathing, and circulation with appropriate airway management.

30-y/o woman with insidious onset of diplopia, scanning speech, paresthesias, and numbness of right upper extremity and urinary incontinence; W/U: MRI shows discrete areas of periventricular demyelination and CSF analysis is positive for oligoclonal bands. (General)

Incurable except in rare patients who can receive allogeneic stem cell transplantation. Autologous stem cell transplantation is sometimes done and appears to prolong survival

A 69-year-old man comes to the office because of altered facial appearance for 2 hours. His wife states that they were eating dinner together, when she looked up and noticed her husband's face looked different. She thinks that his face appeared normal prior to starting dinner. The gentleman states that since eating his dinner, he feels nauseated and like he is on a boat. Medical history includes hypertension for which he takes enalapril. Examination shows a flattened left nasolabial fold and inability to smile on the left side. He is able to raise both of his eyebrows and wrinkle the skin of his forehead bilaterally. Which of the following is the most likely etiology of his condition? A. Idiopathic B. Infiltration C. Infection D. Inflammation E. Infarction

Infarction Facial nerve paralysis can be caused by upper or lower motor neuron lesions. Because of facial nerve anatomy, upper motor neuron lesions (such as ischemic stroke) characteristically have normal strength in upper facial muscles. In contrast, both upper and lower facial muscles are affected equally in lower motor neuron lesions. This man has had an acute cerebral infarction or stroke. This is suggested by his facial nerve paralysis affecting only the lower face, and by his associated symptom of vertigo.

A 74-year-old patient presents to the emergency department with a diffuse headache, difficulty speaking, and right upper limb motor and sensory deficits including weakness and decreased sensation. The patient denies head trauma and admits to gradual worsening over the last 5 hours with one episode of vomiting just before presenting to the ED. Past medical history is significant for chronic sinusitis, hypertension, and hypertriglyceridemia. Which of the following is the most likely diagnosis? (A) Transient ischemic attack (B) Intraparenchymal hemorrhage (C) Subarachnoid hemorrhage (D) Epidural hematoma

Intraparenchymal hemorrhage

A 27-year-old gentleman is brought into the ED after being stabbed in the back by a knife. In addition to the pain from the wound, he complains of weakness in his left leg. Upon physical examination you find that he has no other visible injuries; however, he has 2/5 strength in the left lower extremity. Complete neurologic exam also finds a deficit in vibration sense and light touch on the left lower extremity as well as a loss of pain and temperature sensation in the right lower extremity. Which of the following lesions would result in the syndrome described?

Ipsilateral weakness and loss of light touch and proprioception associated with a contralateral loss of pain and temperature sensation is characteristic of Brown-Sequard syndrome. The weakness in Brown-Sequard is ipsilateral to the lesion, so the answer is left cord hemisection.

A 55-year-old African American man comes to the emergency department because of sudden weakness and numbness on the entire right half of his body. Medical history includes atrial fibrillation and type 2 diabetes mellitus. Examination shows diminished motor strength and sensory deficit in his right extremities. He is unable to follow verbal or written commands and repeat phrases. His speech, however, is spontaneous and of good quality. Which of the following is the most likely cause of the patient's symptoms? A. Intra-cerebral hemorrhage of the middle cerebral artery due to poor sugar control B. Intra-parenchymal hemorrhage due to rupture of the lenticulostriate vessels C. Intracranial hemorrhage into the subarachnoid space from disrupted vessel wall integrity D. Ischemia caused by blockage of the left inferior division of the middle cerebral artery E. Ischemia caused by blockage of the left superior division of the middle cerebral artery

Ischemia caused by blockage of the left inferior division of the middle cerebral artery Ischemic stroke is commonly caused by embolic disease due to atrial fibrillation. Another significant cause of an ischemic stroke is atherosclerosis. Right-sided motor and sensory deficits are caused by contralateral left-sided cerebral involvement which can include Wernicke and Broca area.

A 70-year-old right-handed man is discovered by a family member to have difficulty speaking and comprehending spoken language, and an inability to raise his right arm. He was last known to be normal 1 hour ago when the family member spoke to him by phone. There is a history of treated HTN and diabetes.

Ischemic Stroke

The role of computed tomography (CT) scanning within the first 24 hours of a stroke includes which of the following? A. to exclude hemorrhages B. to exclude tumors C. to exclude abscesses D. to diagnose stroke E. a, b, and c

Ischemic stroke changes usually will not show up on a CT scan or magnetic resonance imaging (MRI) scan within the first 24 hours. Therefore, the role of CT scanning is to rule out structural abnormalities such as hemorrhages, tumors, or abscesses.

A 70-year-old man is brought to the emergency department because of slurred speech, confusion, and weakness in his right side for the past hour. He has complete hemiparesis of his right upper and lower extremities. Patient's medical history is significant for hypertension, atrial fibrillation, and diabetes for the past 26 years. His temperature is 37.8°C (100°F), pulse is 100/min, respirations are 14/min, and blood pressure is 150/92 mm Hg. Oxygen saturation is 94% in room air. Physical examination shows a right-sided facial droop to the lower portion of his face, symmetric forehead wrinkles, and symmetric eyebrow elevation. Which of the following is the most likely diagnosis? A. Acute hemorrhagic stroke B. Acute ischemic stroke C. Bell palsy D. Complex hemiplegic migraine E. Subarachnoid hemorrhage

Ischemic stroke is characterized by the sudden loss of blood circulation to an area of the brain, resulting in a corresponding loss of neurological function. Acute ischemic stroke is caused by thrombotic or embolic occlusion of a cerebral artery and is more common than hemorrhagic stroke. Acute ischemic stroke accounts for 80% of all CVAs, and is from embolism or local thrombosis. CT scan is used for evaluation of early hemorrhagic infarct or subarachnoid hemorrhage. Consider stroke in any patient presenting with acute neurological deficit or any alteration in level of consciousness. Common stroke signs and symptoms are abrupt onset of hemiparesis, monoparesis, or (rarely) quadriparesis, hemisensory deficits, monocular or binocular visual loss, visual field deficits, diplopia, dysarthria, facial droop, ataxia, vertigo, nystagmus, aphasia, and sudden decrease in level of consciousness. The goal for the emergent management of stroke is to complete the following within 60 minutes of patient arrival: assess airway, breathing, and circulation (ABCs) and stabilize the patient as necessary, complete the initial evaluation and assessment, including imaging and laboratory studies, and initiate re-perfusion therapy, if necessary. Ischemic stroke therapies include fibrinolytic therapy, antiplatelet agents, and mechanical thrombectomy.

(Coagulative/Liquefactive) necrosis is seen following an ischemic stroke.

Liquefactive

A 16-year-old woman presents to the emergency department with a recent convulsive episode. The mother reports that this episode occured a few hours after awakening, described her movements as myoclonic, and involving the upper extremity. As time progressed, her myoclonus evolved into a generalized tonic-clonic seizure that lasted 3-4 minutes. The patient reported to sleeping only a few hours per night due to upcoming examinations. Physical exam is unremarkable. EEG shows 5-Hz polyspike and slow-wave discharges.

Juvenile myoclonic epilepsy

what medication is the first line for preventive recurrent partial seizures? a. Benzo b. Kepro

Kepro

25-y/o with h/o bilateral temporal lobe contusions 1 week ago presents with a sudden increase in appetite, sexual desire, and hyperorality.

Klüver Bucy Syndrome

A 40-year-old man presents with increasing muscle weakness. He reports difficulty rising from seated position and difficulty climbing stairs. He denies any blurry vision or any rashes on his body. He has a 100-pack-year history of smoking. Physical exam reveals proximal muscle weakness, decreased deep tendon reflexes, and dry mucous membranes. A bedside edrophonium test is conducted, which is negative. His chest radiography shows a suspicious finding - the round opacity shown in the square.

Lambert-Eaton Syndrome

A 78-year-old man comes to the emergency department because he crashed his car an hour ago. He says he is feeling confused and is unsure what caused him to swerve off the road. He denies a loss of consciousness. He says he had a lot of difficulties filling out his admission paperwork. Particularly, he found writing extremely difficult, and could not sign the document. His vital signs show no abnormalities. Physical examination shows a man with some minor bruises and scrapes. Neurological examination shows an inability to differentiate his left and right, to write, and to distinguish his fingers from one another. There is no further motor or sensory loss. In which of the following is the lesion most likely to be located? A. Left temporal lobe B. Left cerebellar hemisphere C. Left parietal lobe D. Left occipital lobe E. Left frontal lobe

Left Parietal Lobe Gerstmann syndrome is a lesion of the dominant inferior parietal lobe or parietal-temporal cortex and presents with agraphia, finger agnosia, acalculia, and right-left confusion. This man is exhibiting signs of Gerstmann syndrome. This syndrome results from a lesion of the dominant, usually the left, inferior parietal lobe. Most often this is caused by an infarction in this region, which is supplied by the middle cerebral artery and posterior cerebral artery. Ischemic stroke in this region is most commonly caused by atherosclerosis, embolism, and dissection. This syndrome is characterized by agraphia (inability to write), finger agnosia (inability to distinguish the fingers on the hand), acalculia (difficulty learning or understanding mathematics), and right-left confusion. This can be remembered using the mnemonic, "Gerstmann came from AFAR," Agraphia, Finger agnosia, Acalculia, and Right-left confusion. In addition to exhibiting the above symptoms, many adults also experience aphasia, which is a difficulty in expressing oneself when speaking, in understanding speech, or in reading and writing. Treatment of Gerstmann syndrome is largely supportive. Engagement with occupational therapists and speech language therapists may enable patients to reduce the burden of this illness on their daily life.

A 60-year-old man is brought to the emergency department because of right upper and lower extremity weakness and the inability to speak for the past day. Medical history is significant for hypertension and coronary artery disease. Physical examination shows that he is able to follow verbal commands, understands what you are saying to him, but patient is unable to form words. Further physical examination shows 3/5 strength in his right lower extremity, 0/5 strength in the right upper extremity, and 5/5 on the left upper and lower extremities. Which of the following arteries is most likely affected in this patient's condition? A. Internal thoracic artery B. Left middle cerebral artery C. Lenticulostriate arteries D. Posterior inferior cerebellar artery E. Right anterior cerebral artery

Left middle cerebral artery The left middle cerebral artery supplies the cortical motor output to the right side of the body, primarily the upper extremity, and it also supplies Broca area. It is important to know the blood supply to the different regions of the brain and the function of each part of the brain.

A 74-year-old man is admitted to the hospital after waking up with slurred speech and paralysis on the right side of his body. Paralysis is present on the left side of his face, his right arm, and his right leg. Neurologic examination reveals hyperreflexia on his right side and a positive Babinksi's sign on his right foot. His sensory examination was normal. An incident in which of the following areas of the brain likely caused these symptoms in the patient? A. Left dorsal medulla B. Left dorsal pons C. Left postcentral gyrus D. Left precentral gyrus E. Left ventral pons

Left ventral pons A lacunar infarct near the left ventral pons would likely affect the pyramidal portion of the corticospinal tract, which would affect muscle innervation on the contralateral, or right, side.

A 62-year-old man comes to the clinic for problems with his balance and gait. He noticed he has been unsteady while walking. He denies any joint pain or a history of trauma. He does admit that his limbs become rigid at times. On physical examination, he has a slow shuffling gait and a tremor in his hands while at rest that improves with movement. There is also rigidity in his upper extremities upon passive movement. Which of the following is the first-line pharmacologic therapy to control symptoms in this patient's condition? A. Haloperidol B. Levodopa C. Memantine D. Riluzole E. Selegiline

Levodopa Levodopa is the first-line agent used to treat symptoms of Parkinson disease. Although there is no cure for this condition, supplementing dopamine in the brain has been shown to improve symptoms. The caudate nucleus and putamen are the primary regions that are affected in this disorder.

60-y/o presents with gradual onset of pill-rolling tremor; PE: masked facies, stooped posture, festinating gait, cogwheel muscle rigidity

Levodopa/carbidopa: The gold standard for symptomatic treatment. Levodopa, a precursor of dopamine, is administered with carbidopa, a decarboxylase inhibitor that inhibits peripheral conversion of levodopa to dopamine. Should be taken on an empty stomach to maximize absorption. Dopamine agonists: Direct agonists of D2 dopamine receptors. Catechol-O-methyltransferase (COMT) inhibitors: One pathway of dopamine degradation is via COMT; inhibition of this enzyme raises endogenous dopamine levels MAO-B inhibitors: Another pathway of dopamine degradation is via MAO; inhibition of this enzyme likewise raises endogenous dopamine levels

A 67-year-old male presents with poor attention and getting lost while driving. He is accompanied by his wife. She reports that he would have episodes of staring into space and disorganized speech. His wife also reports that he would have full conversations with himself in the living room. She says that he was talking to his brother, who is deceased. Postural instability and bradykinesia is noted on physical exam.

Lewy Body Dementia

A 47 year old male patient walks into the ER today. His muscles were stiffened followed by repetitive jerking. This went one for about 31 minutes without recovery from the post ictal period. His wife told the paramedics who responded that she found his lamictal bottle full since he picked it up from the pharmacy 1 month ago. What is the first line of treatment for this patient. a. Lamictal b. Phenytoin c. Lorazepam d. Oxycodone

Lorazepam

A 32-year-old woman is brought to your office by her husband. The husband says that she had been acting strange lately. She has been forgetful, and she sometimes becomes angered for no reason, which is highly unusual for her. She has also been having random, uncontrollable movements, which are also new. On examination, she appears withdrawn and flat. On further questioning, she reveals that her father died at age 45 from a movement disorder. Which of the following is the pathological hallmark of the patient's condition? Substantia nigra pars compacta Alpha-synuclein intracellular inclusions Loss of neurons in the caudate nucleus and putamen Lipohyalinosis Beta-amyloid plaques

Loss of neurons in the caudate nucleus and putamen Huntington's disease is a progressive neurodegenerative disorder characterized by loss of neurons in the caudate nucleus and putamen.

A 65-year-old man comes to the clinic because of problems with his balance and gait that has worsened over the past couple of weeks. He noticed he has been unsteady while walking. He denies any joint pain or a history of trauma. He admits that his limbs become rigid at times. He has a history of hypertension that is well controlled. On physical examination, he has a slow shuffling gait and a tremor in his hands while at rest that improves with movement. There is also rigidity in his upper extremities upon passive movement. Which of the following is a pathological hallmark of this patient's disease? A. Development of visual hallucinations B. Beta-amyloid plaques C. Lipohyalinosis D. Loss of neurons in the caudate nucleus and putamen E. Loss of neurons in the substantia nigra pars compacta

Loss of neurons in the substantia nigra pars compacta is associated with Parkinson disease, which is characterized by pill-rolling tremors at rest, rigidity, akinesia, dementia, postural instability and shuffling gait. The loss of these dopaminergic neurons creates an imbalance in the thalamus, and is the root of the motion issues seen in the disorder.

55-y/o man presents with lower extremity weakness and muscle atrophy; PE: positive Babinski reflex, upper extremity hyperreflexia, and spasticity.

Lou Gehrig's Disease

A 60-year-old patients develops a sudden severe headache followed by a decreased level of consciousness. Blood work and a computed tomography (CT)scan of the head without contrast are normal. What is the most appropriate next step in evaluating this patient? A. CT scan of the head with contrast B. Electroencephalography (EEG) C. Lumbar puncture D. Magnetic resonance imaging (MRI) of the brain E. Tilt-table testing

Lumbar puncture

A 77-year-old male with hypertension and a 46 pack year history presents to the Emergency Department from an extended care facility with acute onset headache, nausea, vomiting, and neck pain which began 2 days prior. He is alert, but his baseline level of consciousness is slightly diminished per the nursing home staff. He is immediately sent for an urgent head CT, which is normal. What is the most appropriate next step in his management? Brain MRI EEG Ultrasound (echoencephalography) Lumbar puncture Cerebral angiography

Lumbar puncture In a patient with high pre-test probability of aneurysmal subarachnoid hemorrhage with a normal head CT, a lumbar puncture is indicated to assess for xanthochromia.

A 27 year-old female presents to your office for evaluation of weakness, visual loss, and sensory loss over the right great toe. These symptoms have occurred during three episodes approximately three months apart with each episode lasting about three days. Which of the following tests would be most useful in further evaluating this patient? A. MRI of the brain B. Electromyograph C. Glucose tolerance test D. Electroencephalograph

MRI of the brain

A 45 year old women arrives at your primary care office c/o back pain. She has noticed over the past couple weeks that she is having trouble at the gym with leg exercises that she has been doing for years. What diagnostic test should be ordered first to further diagnose this patient? A. MRI w/ contrast B. MRI w/o contrast C. Genetic testing D. CT

MRI w/ contrast

30-y/o woman with insidious onset of diplopia, scanning speech, paresthesias, and numbness of right upper extremity and urinary incontinence; W/U: MRI shows discrete areas of periventricular demyelination and CSF analysis is positive for oligoclonal bands.

MS

A 38 yr old female comes to the office because of intermittent blurring of vision in her right eye for 1 year. She says these episodes usually last a week, and then completely resolve. Other symptoms she has intermittently experienced are difficulty in maintaining balance while walking and urinary urgency. An MRI scan of her brain is obtained and revealed plaques. What is the most likely diagnosis? A. ALS B. MS C. Bell Palsy D. Myasthenia Gravis

MS

A 59-year-old male presents to his primary care physician complaining of a tremor. He developed a tremor in his left hand approximately three months ago. It appears to be worse at rest and diminishes if he points to something or uses the hand to hold an object. His past medical history is notable for emphysema and myasthenia gravis. He has a 40 pack-year smoking history. Physical examination reveals slowed movements. The patient takes several seconds to rise from his chair for a gait analysis which reveals a shuffling gait. The physician decides to start the patient on a medication that prevents the degradation of a neurotransmitter. This medication is also indicated for use in which of the following conditions? Major depressive disorder Influenza Seasonal allergies Hyperprolactinemia Restless leg syndrome

Major Depressive Disorder The patient in this vignette presents with resting tremor, bradykinesia, and a shuffling gait suggestive of Parkinson's disease. Selegiline is a monoamine oxidase inhibitor that is used to treat both Parkinson's disease and major depressive disorder.

After a long tour around the world, a Pianist starts noticing pain, numbness, tingling in the first 3 digits and radial half of 4th digit at night time. What is your diagnosis, and what is the proper treatment? a. Ulnar Neuropathy, Treatment:NSAIDs b. Ulnar Neuropathy, treatment: Padding elbow c. Median Neuropathy, Treatment: NSAIDs d. Median Neuropathy, Treatment: Padding elbow

Median Neuropathy, Treatment: NSAIDs

A 35 yo female patient with a h/o diabetes and obesity presents to your office complaining of a loss of sensation on the median side of her palm from her thumb to her ring finger. She has been experiencing an aching and shooting pain in the area and this morning felt weakness and had difficulty pouring her coffee. She denies any arm or dorsal hand weakness/pain. What is the likely diagnosis? A. Median neuropathy (Carpal Tunnel Syndrome) B. Cervical radiculopathy C. Ulnar neuropathy D. Radial neuropathy

Median neuropathy (Carpal Tunnel Syndrome)

65-y/o woman with h/o neurofibromatosis type 2 presents with headache, right-sided leg jerking, and worsening mental status; PE: papilledema and right-sided pronator drift; W/U: CT scan shows dural-based, enhancing, left-sided softball-sized tumor.

Meningioma

40-day-old M is brought to the ER because of irritability and lethargy, vomiting, and ↓ oral intake of three days' duration. Today his parents noted that he had a fever of 101.5°F, and he subsequently had a seizure. The baby's weight at delivery was 2500 grams, and he has been well. VS: T 39°C (102°F), P 160, BP 77/50, RR 40, O2 sat 92% room air Gen: Irritable infant Lungs: Clear CV: Tachycardia; I/VI systolic murmur Abd: WNL Neuro/psych: Bulging fontanelle, ↓ responsiveness

Meningitis

A 19-year-old male is brought to the emergency department by his college roommate due to confusion and difficulty with arousing from sleep. The patient reports severe generalized headache, neck stiffness, and muscle aches. Temperature is 102.2°F (39°C), blood pressure is 102/68 mmHg, pulse is 107/min, and respirations are 22/min. On physical exam, a petechial rash is distributed on the thorax and extremities. While supine, neck flexion lead to involuntary knee flexion.

Meningococcal meningitis

A 42-year-old man comes to clinic with difficulty walking. He is an actor and has been having trouble moving around the set. He complains of feeling "off-balance" and has fallen several times. He suffers from occasional headaches for which he takes ibuprofen, but is otherwise healthy. He does not smoke and takes no medications. He denies blurry vision, neck stiffness, leg pain, nausea, or recent illness. His temperature is 36.6°C (98.3°F), pulse is 85/min, respirations are 16/min, and blood pressure is 116/80 mm Hg. He is a well-appearing young man, sitting comfortably. He repeatedly rubs his right thumb and first digit together. Pupils are equal, round and reactive to light and accommodation. He has no facial droop or ptosis. On gait examination, it takes him multiple steps to turn around. He scores 28/30 on Mini-Mental Status Examination. A lesion in which location is most likely responsible for this patient's symptoms? A. Cerebellum B. Hippocampus C. Midbrain D. Striatum E. Vestibulocerebellar circulation

Midbrain Parkinson's disease is a movement disorder caused by brain cell death in the substantia nigra, a part of the mid-brain. Common presenting symptoms include rigidity, bradykinesia-akinesia, and a pill-rolling tremor.

A 68-year-old woman comes to the emergency department because of acute onset of generalized right body weakness and left-sided ptosis. Her medical history is relevant to type II diabetes, high blood pressure, and coronary artery disease. She currently takes dual antiplatelet therapy, telmisartan, and metformin. Physical examination shows right side hemiplegia, and her left pupil is pointed down and out. The patient claims to have problems while walking and that she stumbles easily. While watching her walk you notice a shuffling gait on her right leg. Her temperature is 36.7°C (98°F), pulse is 80/min, respirations are 16/min, blood pressure is 130/90 mm Hg. Which of the following areas is most likely damaged? A. Cerebellum B. Internal capsule C. Medulla D. Midbrain E. Pons

Midbrain The patient in the vignette is experiencing Weber's syndrome. Weber's syndrome (also known as superior alternating hemiplegia) is a rare midbrain stroke syndrome characterized by the presence of an ipsilateral oculomotor cranial nerve palsy and contralateral hemiparesis or hemiplegia. This condition is caused by a midbrain infarction as a result of occlusion of the paramedian branches of the posterior cerebral artery. This lesion is usually unilateral and affects several structures in the midbrain, such as oculomotor nerve fibers, substantia nigra, corticospinal fibers, corticobulbar tract. Given the anatomical disposition of tract fibers and the lesion, symptoms will be characteristically contralateral to the lesion. For example, damage to substantia nigra will result in contralateral parkinsonism because its dopaminergic projections to the basal ganglia innervate the ipsilateral hemisphere motor field, leading to a movement disorder of the contralateral body (i.e., right shuffling gait). Similarly, contralateral hemiparesis and upper motor neuron findings happen because it occurs before the decussation in the medulla. Lastly, patients present with ipsilateral oculomotor nerve palsy with diplopia and fixed wide pupil pointed down and out.

21 yo F presents with a severe headache. She has a history of throbbing left temporal pain that lasts for 2-3 hours. Before these episodes start, she sees flashes of light in her right visual field and feels weakness and numbness on the right side of her body for a few minutes. The headaches are often associated with nausea and vomiting. She has a family history of migraine. VS: T 37°C (99.2°F), P 70, BP 120/80, RR 15, O2 sat 100% room air Gen: NAD Lungs: WNL CV: WNL Abd: WNL Ext: WNL Neuro: WNL

Migraine

30-y/o woman presents with unilateral throbbing headache, nausea, photophobia, scotoma; similar symptoms occur monthly at the same time of her menstrual cycle.

Migraine

A 24-year-old white woman has a 12-year history of headaches. These headaches started in grade school, and the patient remembers missing school because of her headaches. Typically, she gets one of these headaches one to two times per month. The headache starts over the right eye, and the headache is usually preceded by flashing lights and zigzag lines. Once the headache begins, there is extreme nausea and vomiting, and the patient goes into a dark room to minimize her head pain. Generally, the headache lasts 4 to 6 hours, but the patient feels tired and listless for the next 24 hours. The patient feels that the headache worsens with her menstrual cycle, and certain foods especially red wine can exacerbate her headache. Her general and neurologic examinations are normal.

Migraine

A 32-year-old woman presents with a 13-year history of 1 to 3 attacks per month of disabling pounding pain over one temple, with nausea and sensitivity to light. She says that her headaches can be triggered by lack of sleep and made worse by physical exertion, and are more common during menstrual bleeding. Untreated, they last for 2 days. On 4 occasions, headaches were preceded by the gradual appearance of a shimmering, zigzag line that enlarged, moved to the peripheral visual field and then faded away over 45 minutes. Examination is normal.

Migraine

A 40-year-old man complains of a 1-year history of twice-monthly global headache, worse on the left side in the postauricular region. It comes on gradually and, at its most severe, the vision in his left eye becomes distorted. He often has to stop watching television as the picture becomes "blurry." His nose becomes blocked, although sometimes he has a "runny nose." He takes a nonsteroidal anti-inflammatory drug (NSAID) that helps a little, but he feels that his head is about to explode at times. When the headache occurs, he needs to go into a dark quiet room and sleep until it resolves. He reports the problem is "really getting him down," and he is having difficulties with his employer due to loss of work time.

Migraine

A 33-year-old woman presents to her primary care physician with headache, nausea, and visual disturbances. The patient was in her usual state of health until yesterday, when she experienced a pulsatile bilateral headache that caused her to have one episode of emesis. Her headache is accompanied by seeing a shimmering light that distorts her vision, photophobia, and phonophobia. Medical history is unremarkable, and the patient recently began menses. Ibuprofen and acetaminophen have not improved her symptoms. Neurologic examination is unremarkable.

Migraine headaches

A 30 y/o female presents with vision loss that progressed over the last 7 days. She states that she has been experiencing pain when she moves eyes. On PE, the PA noted papilledema, nystagmus, hyperreflexia and muscle spasticity. What is the most likely diagnosis? A) Multiple sclerosis B) Neuromyelitis optica C) Acute glaucoma D) Optic Neuritis

Multiple sclerosis

A 64-year-old right handed man comes to the primary care office complaining of involuntary "twitches" of his left hand. He first noticed this 6 months ago when his left hand starting shaking at rest. The shaking stops when he looks at his hand and concentrates. The shaking does not impair his activities. There is no tremor in his right hand, and the lower extremities are not affected. He has had no trouble walking. There have been no behavioral or language changes. On examination, you witness a left hand tremor is evident when he is distracted. Handwriting is mildly tremulous. He is very mildly bradykinetic on the left. Which of the following is most likely to also be found on examination? A. Upper motor neuron pattern of weakness on the left B. Bilateral upper and lower motor neuron pattern of weakness C. Lower motor neuron pattern of weakness on the left D. Sudden, jerky movements on the left E. Mild cogwheel rigidity on the left only with distraction

Mild cogwheel rigidity on the left only with distraction Parkinson's disease is a movement disorder that usually presents with the classic triad of asymmetric resting tremor, cogwheel rigidity, and bradykinesia

A 24-year-old graduate student was studying late at night for an examination. As he looked at his textbook, he realized that his left arm and left leg were numb. He dismissed the complaint, recalling that 6 or 7 months ago he had similar symptoms. He rose from his desk and noticed that he had poor balance. He queried whether his vision was blurred, and remembered that he had some blurred vision approximately 1 to 2 years earlier, but that this resolved. He had not seen a physician for any of these previous symptoms. He went to bed and decided that he would seek medical consultation the next day.

Multiple Sclerosis

A 28-year-old white woman who was raised in the northern US and has smoked 1 pack per day for the last 10 years presents with subacute onset of cloudy vision in 1 eye, with pain on movement of that eye. She also notes difficulty with color discrimination, particularly of reds. She was treated for a sinus infection 2 weeks ago and on further history recalls that she had a 3-week history of unilateral hemibody paresthesias during finals week in college 6 years ago. She occasionally has some tingling on that side if she is overly tired, stressed, or hot.

Multiple Sclerosis

A 31-year-old woman with strong FHx of autoimmune disease is 6 months postpartum and develops ascending numbness and weakness in both feet, slightly asymmetrically, over a period of 2 weeks. She gradually develops difficulty walking to the point where she presents to an ER and is also found to have a UTI.

Multiple Sclerosis

A 32-year-old women presents to her physician complaining of double vision. This has been very distressing for her. She has a past medical history significant for type 1 diabetes, treated with a continuous subcutaneous insulin pump. Upon further questioning, she mentions she experienced arm weakness and numbness that resolved spontaneously over the course of a couple weeks. Physical examination is notable for impaired adduction of the right eye, and nystagmus on abduction of the left eye on left lateral gaze.

Multiple Sclerosis

A 42-year-old woman presents to her primary care physician for fatigue. She reports that her fatigue is worse towards the end of the day. She also notes that while bathing her nephew in the shower her head would "drop." At times when she is watching television or reading a book she sees double. Lastly, she would see her left or right eyelid droop after returning from work. On physical exam, there is right-sided ptosis after sustaining upward gaze for a few minutes. A tensilon test is performed, which is demonstrated in the clinical image below. Serologic studies return positive for anti-acetylcholine receptor antibodies. Preparations are made to have a computerized tomography scan of the chest.

Myasthenia Gravis

A 57 year-old male presents with episodic diplopia over the past two months. Symptoms progressed over the last two days with the onset of bilateral facial weakness made worse with repetitive use. Weakness improves somewhat with rest. He denies fever, headache or areas of pain. Exam reveals a nasal voice, drooping eyelids and a normal sensory exam. Which of the following is the most likely diagnosis? A. Multiple sclerosis B. Guillain-Barre syndrome C. Lambert-Eaton syndrome D. Myasthenia gravis

Myasthenia gravis

A 58-year-old woman presents with symptoms of daytime sleepiness and fatigue, with difficulties concentrating at work. She drinks several cups of coffee during the day to keep awake. She goes to bed at 10 p.m. on most nights, and reports falling asleep within 15 minutes. She sets her alarm for 6.30 a.m. She is often aware of waking during the night, although she is not sure why, and reports feeling unrefreshed in the morning. Her husband describes her as "a restless sleeper" and says that her nighttime movements often wake him up. She snores occasionally, although there is no history of waking with a dry mouth or morning headache. There is no significant past medical history, and she takes no regular medications. On examination, her body mass index is 23.5. Physical exam is normal. Her Epworth Sleepiness Scale score is 17/24 (normal <11). Routine blood tests are normal.

Myoclonus

irregular involuntary contraction of a muscle Bradykinesia Dyskinesia Myoclonus Athetosis Tremor

Myoclonus

29 yo F presents with daily episodes of bilateral bandlike throbbing pain in her frontal-occipital region that last between 30 minutes and a few hours. She usually experiences these episodes when she is either tired or under stress. She denies any associated nausea, vomiting, phonophobia, photophobia, or aura. She also feels pain and stiffness in her neck and shoulder. VS: Afebrile, P 70, BP 120/80, RR 15 Gen: NAD Lungs: WNL CV: WNL Abd: WNL Ext: WNL Neuro: WNL

NSAIDs or acetaminophen. Relaxation techniques may be helpful.

45-y/o presents with the gradual onset of sharp pain radiating from his buttocks down his leg that began 2 weeks ago when he began to lift a heavy box; PE: positive straight leg raise test

NSAIDs, physical therapy, and local heat. Usually resolves in 4 weeks. Severe disease is an indicator for discectomy

25-y/o with h/o bilateral temporal lobe contusions 1 week ago presents with a sudden increase in appetite, sexual desire, and hyperorality.

Neurology consult

36-y/o woman with family h/o renal cell carcinoma presents with gait disturbance and blurred vision; PE: retinal hemangiomas, nystagmus, cerebellar ataxia, dysdiadokinesia; MRI shows two cerebellar cystic lesions.

Neurology consult

65-y/o with urinary incontinence, loss of short-term memory, and dementia; PE: wide based, magnetic gate; W/U: CT scan shows massively dilated ventricular system

Neurosurgery consult Neurology consult Ventriculoperitoneal shunt

79 yo M is brought in by his family complaining of a seven-week history of difficulty walking accompanied by memory loss and urinary incontinence. Since then he has had ↑ difficulty with memory and more frequent episodes of incontinence. VS: P 92, BP 144/86, RR 14 Gen: NAD Lungs: WNL CV: WNL Abd: WNL Ext: WNL Neuro: Difficulty with both recent and immediate recall on mini-mental status exam; spasticity and hyperreflexia in upper and lower extremities; problem initiating gait (gait is shuffling, broad-based, and slow

Neurosurgery consult Neurology consult Ventriculoperitoneal shunt

________________ is a calcium channel blocker commonly used to treat the vasospasm seen in subarachnoid hemorrhage two to three days after the injury.

Nimodipine

A 75-year-old man is brought to the emergency department because of bilateral visual loss and muscle weakness for the past 4 hours. The man has an extensive history of poorly controlled hypertension and does not recall any precipitating events to this episode. A physical examination shows visual loss in both eyes. He has a muscle strength of 1/5 in his right shoulder and thigh. Which of the following is the next appropriate step in management for this patient? A. Latanoprost B. Non-contrast computed tomography scan C. Brain natriuretic protein levels D. Tissue plasminogen activator E. Mannitol

Non-contrast computed tomography scan A watershed stroke is an ischemic stroke of the distant border regions where two arteries meet. These patients can experience bilateral vision loss and weakness in the thighs and shoulders. A non-contrast computed tomography scan should be the first step in management. A watershed stroke is used to describe an ischemic stroke of the border zones where the anterior cerebral, posterior cerebral, and middle cerebral arteries meet to form dual circulation. These border zones are known as watershed regions because that is where blood flow is at its lowest. Hence, patients with cardiovascular disease such as congestive heart failure, hypertension, and carotid artery stenosis are prone to suffering from watershed strokes due to the hypoperfusion of these locations. Ischemic watershed strokes will show up on magnetic resonance imaging or computed tomography imaging as a "wedge" appearance. Like other strokes, watershed strokes should be recognized using the FAST protocol (facial droop, arm weakness, slurred speech, and time to intervention). Patients with watershed stroke will classically show bilateral vision loss with weakness of the arms and shoulders. This is sometimes known as the "man inside the barrel" because of the sparing of the face, hands, and feet. Once recognized, the first step in management and diagnosis should be a non-contrast computed tomography scan of the head. This will rule out hemorrhagic stroke. Then, depending on the time frame and etiology, tissue plasminogen activator can be administered.

65-y/o with urinary incontinence, loss of short-term memory, and dementia; PE: wide based, magnetic gate; W/U: CT scan shows massively dilated ventricular system

Normal Pressure Hydrocephalus

79 yo M is brought in by his family complaining of a seven-week history of difficulty walking accompanied by memory loss and urinary incontinence. Since then he has had ↑ difficulty with memory and more frequent episodes of incontinence. VS: P 92, BP 144/86, RR 14 Gen: NAD Lungs: WNL CV: WNL Abd: WNL Ext: WNL Neuro: Difficulty with both recent and immediate recall on mini-mental status exam; spasticity and hyperreflexia in upper and lower extremities; problem initiating gait (gait is shuffling, broad-based, and slow

Normal Pressure Hydrocephalus

A 58 year old man is brought into the ED because of an extremely high fever. He is diagnosed with encephalitis and subsequently develops a stroke. He continues to deteriorate. After 6 days, he becomes unresponsive to painful stimulus and brain death is suspected. Which of the following non-neurological assessments is a prerequisite in establishing that brain death has occured? A)Liver function test B)Absent spinal reflex C)Normal blood pressure D)Decerebrate posture

Normal blood pressure

A 62-year-old man presents to his primary care physician due to trouble with walking and difficulty with concentrating. The patient describes his walking as if he is "stuck to the ground." On gait testing, the patient has magnetic gait and on montreal cognitive assessment (MoCA) testing, he has a deficit in executive functioning. Laboratory tests are ordered and return normal. Lumbar puncture shows a normal opening pressure and magnetic resonance imaging (MRI) of the head is shown.

Normal pressure hydrocephalus

60 yo M was found unconscious by his wife, who called the paramedics. She left him in bed at 7 A.M. to go to her volunteer job. When she returned for lunch at 1 P.M., she found an empty bottle of amitriptyline next to him. When paramedics arrived, he was noted to be in respiratory distress and was transferred to the ER VS: T 38°C (101°F), P 110, BP 95/45, RR 35, O2 sat 89% on 100% face mask Gen: Acute distress; shallow, rapid breathing HEENT: Dilated pupils Lungs: WNL CV: Tachycardia Abd: WNL Neuro: Opens eyes to painful stimuli Limited PE

Observe for at least 6 hours, and admit if there is evidence of anticholinergic effects Activate charcoal Sodium bicarbonate (50-100 mEq IV) Consider plasma exchange and lipid evulsion

20-y/o presents with nausea, vomiting, and headache 2 hours after being hit in the temple with a baseball; patient lost consciousness initially but recovered quickly; W/U: CT shows lens-shaped, right-sided hyperdense mass adjacent to temporal bone

Open craniotomy and blood evacuation

A patient presents with progressive visual changes over the past 2 years. On physical examination, bitemporal hemianopsia is noted. A lesion in which of the following anatomic locations is most likely to cause these findings? A. Optic Nerve B. Optic chiasm C. Optic radiation D. Optic tract

Optic chiasm

A 75 y/o female presents to the ED c/o headache, slurred speech, and dizziness. She reports she felt well when she went to sleep at 9:00PM and awoke at 8:00AM with symptoms. On exam, patient has right finger to nose dysmetria and horizontal nystagmus. CT head w/o contrast shows no acute ICH. What is the next best course of action? a. Treat the patient with tPA for ischemic cerebellar stroke. b. Order CTA head and neck w/ contrast to localize possible occlusion. c. Order Carotid US to evaluate for stenosis. d. Order MRI Brain w/o contrast to identify stroke

Order CTA head and neck w/ contrast to localize possible occlusion

Paralysis of both legs and part of trunk Akinesia Apraxia Paraplegia Paresis

Paraplegia

Partial paralysis Akinesia Apraxia Paraplegia Paresis

Paresis

60-y/o presents with gradual onset of pill-rolling tremor; PE: masked facies, stooped posture, festinating gait, cogwheel muscle rigidity

Parkinson Disease

A 63-year-old male is brought to the physician by his wife for the evaluation of a tremor. The tremor is worse at rest, and decreases in severity with purposeful movement. The patient reports to having difficulty with initiating voluntary movement, and his wife states that the patient's movements have been slow. On exam, there is seborrheic dermatosis on the nasolabial folds. There is a "pill-rolling" resting tremor accentuated when the patient is asked to perform mental calculations. Resistance to passive movement at the elbow joint is noted. On gait testing, there was difficulty with initiating gait, as well as the patient taking short steps when walking forward.

Parkinson Disease

A 58-year-old patient presents to the office with a complaint of tremor in the right hand at rest. Upon questioning, it is discovered that the tremor is getting worse and now seems to be in both arms especially when at the patient's sides. The patient also complains that food does not smell as good now and they are having trouble eating with a fork and buttoning their shirt. On physical examination, the provider notices a resting tremor, bradykinesia, rigidity, and a shuffling gait. What is the initial assessment? (A) Essential tremor (B) Wilson disease (C) Huntington disease (D) Parkinson disease

Parkinson disease

_______________ is a movement disorder of the basal ganglia that presents with resting tremor, cogwheel rigidity, akinesia/ bradykinesia, postural instability and shuffling gait.

Parkinson disease

__________________ is a movement disorder that involves degenerative loss of dopaminergic neurons of the substantia nigra of the basal ganglia.

Parkinson disease

A 63 year old female presents with a 12 month history of hemiparesis. Physical examination notes a stooped posture with very slow movements and a fixed facial expression. The patient appears rigid and has difficulty getting up from a sitting position. What is the most likely diagnosis? A. Multiple Systems Atrophy B. Amyotrophic Lateral Sclerosis (ALS) C. Parkinson's Disease D. Combined systems degeneration E. Alzheimer's Disease

Parkinson's Disease

A 69-year-old man presents with a 1-year history of mild slowness and loss of dexterity. His handwriting has become smaller, and his wife feels his face is less expressive and his voice softer. Over the last few months he has developed a subtle tremor in the right hand, noted while watching television. His symptoms developed insidiously but have mildly progressed. He has no other medical history, but he has noted some mild depression and constipation over the last 2 years. His examination demonstrates hypophonia, masked facies, decreased blink rate, micrographia, and mild right-sided bradykinesia and rigidity. An intermittent right upper extremity resting tremor is noted while he is walking. The rest of his examination and a brain MRI are normal.

Parkinson's Disease

Mr.Stones displays shuffling with narrow base gait, intentional tremors, and a masked fascies. As the PA you order a CT and MRI, which results are normal. What neurological disease may this patient have? A) Huntington's disease B) Essential tremor C) Parkinson's disease D) None of the above

Parkinson's disease

The patient is a 55-year-old man in good health until about 6 months ago. At that time he noticed the development of a tremor. He has no other complaints. On examination, there is a tremor in the right arm at rest and while he walks, he has a sustained tremor in both arms, and to some degree during finger-nose-finger maneuvers (fairly fine and without an obvious rhythm). He has a poker face and a slow, deliberate gait. Tone is increased in the right arm and leg. The physical examination is otherwise unremarkable. He and his wife deny his use of alcohol or any other medications.

Parkinson's disease

A 63-year-old man comes to the clinic with a several-month history of difficulty with his gait and coordination. He finds walking difficult and has almost fallen on a number of occasions, especially when trying to change directions. He has also found that using his hands is difficult, and other people have noticed that his hands shake. Physical examination is notable for a resting tremor in the hands that disappears with intentional movement. He has a shuffling gait with difficulty turning. There is so-called cogwheeling rigidity in his arms, a jerky sensation with passive flexion and extension of the arms.

Parkinsons Disease

A 62 y.o male patient comes into your Primary Care Office complaining of a new onset slurred speech. Patient reports that this has been going on for the past 3 hours. Patient does not complain about anything else. Patient has a history of DM and is being managed on metformin. Patient's vitals are taken. BP 162/92, RR 16, PR 84, 96% O2, 98.4F oral. A. Patient should be admitted into the hospital for further testing/management B. Patient should be sent home and monitor for 24 hours and report any changes in symptoms to PCP/PC PA next week C. Outpatient referral to the neurologist D. Patient should be sent to a Stroke Center for imaging and evaluation

Patient should be sent to a Stroke Center for imaging and evaluation

Which of the following is a classic symptom of subarachnoid hemorrhage? A. Seizure B. Aphasia C. Photophobia D. Numbness/weakness

Photophobia The hallmark of subarachnoid hemorrhage is the immediate onset of severe headache with signs of meningeal irritation. Individuals may describe this headache as their "worst ever." Nausea, vomiting, neck pain, and photophobia are also classic symptoms, although they are not always present. Neurological deficits may be acute or may manifest hours to days after the onset of the bleeding.

30-y/o woman with insidious onset of diplopia, scanning speech, paresthesias, and numbness of right upper extremity and urinary incontinence; W/U: MRI shows discrete areas of periventricular demyelination and CSF analysis is positive for oligoclonal bands. (Goal is to prevent infections)

Pneumococcal and Haemophilus vaccines if not already immune. Reduce paraprotein.

A 56-year-old man is brought to the emergency department because of sudden onset posterior cranium headache, acute vision loss, and confusion. Patient says he feels dizzy and with nausea. His son says that he has been bumping into objects since headache started. Patient rates the pain as a 9 on a 10-point scale. Medical history is significant for atrial fibrillation and hypertension. Physical examination shows a fixed, bilateral, homonymous visual-field cut. Which of the following is the most likely diagnosis? A. Anterior cerebral artery stroke B. Carotid stenosis C. Middle cerebral artery stroke D. Posterior cerebral artery stroke E. Vertebral artery atherothrombosis

Posterior cerebral artery stroke syndrome is a condition whereby the blood supply from the posterior cerebral artery (PCA) is restricted, leading to a reduction of the function of the portions of the brain supplied by that vessel: the occipital lobe, the inferomedial temporal lobe, a large portion of the thalamus, and the upper brainstem and midbrain. The most common long-term sequelae of PCA strokes are visual and sensory deficits.

A 72-year-old woman is brought to the emergency department because she fell suddenly while mowing the lawn. The patient says that she was in her garden when all of the sudden she felt dizzy, nauseous, and fell without losing consciousnesses. She has past medical history of hypertension, diabetes mellitus, atrial fibrillation, and atherosclerosis. Physical examination shows a right-sided ptosis, loss of lacrimation, and a pupil of 2 mm and minimally responsive to light. Her left eye shows no abnormalities. Neurological examination shows decreased sensation to pain and temperature on the right side of the face and left side of her upper and lower extremities, dysphagia, and ataxia. Which of the following arteries is most likely involved in her condition? A. Anterior cerebral artery B. Anterior spinal artery C. Left external carotid artery D. Middle cerebral artery E. Posterior inferior cerebellar artery

Posterior inferior cerebellar artery Occlusion of the posterior inferior cerebellar artery causes Wallenberg Syndrome (lateral medullary syndrome). Hallmark symptoms include hoarseness and dysphagia. Lateral medullary syndrome (also called Wallenberg syndrome and posterior inferior cerebellar artery syndrome) is a disorder in which the patient has a constellation of neurologic symptoms due to injury to the lateral part of the medulla in the brain, resulting in tissue ischemia and necrosis. This syndrome is characterized by sensory deficits affecting the trunk (torso) and extremities on the opposite side of the infarction and sensory deficits affecting the face and cranial nerves on the same side with the infarct. Specifically, there is a loss of pain and temperature sensation on the contralateral (opposite) side of the body and ipsilateral(same) side of the face. This crossed finding is diagnostic for the syndrome. Clinical symptoms include swallowing difficulty, or dysphagia,slurred speech, ataxia, facial pain, vertigo, nystagmus, Horner syndrome, diplopia, and possibly palatal myoclonus.

50-y/o with h/o polycystic kidney disease presents with "worst headache of life," photophobia, nausea; PE: right eye deviated down and out; W/U: CSF is xanthrochromic.

Preventing rebleeding CCBs and IV fluids; maintain BP to prevent vasospasm and further neurologic deterioration Seizure prophylaxis Decrease ICP by raising the head of the bed and instituting hyperventilation Surgical treatment involves open clipping or endovascular coiling of vascular abnormalities

A 59-year-old man comes to clinic with complaints of "shakiness" in his hands. His tremor is most noticeable when he is holding something or writing, and is more prominent in his hand than in his shoulder. He has noticed that it seems better with alcohol. His only medication is an albuterol rescue inhaler for his long-standing asthma. On examination there is a very definite tremor while he unbuttons his shirt. His gait is normal and there is no resting tremor. He has a previous history of asthma. Which of the following medications would be the best choice for this patient? A. Propranolol B. Amantadine C. Primidone D. Lorazepam E. Levodopa/carbidopa

Primidone Essential tremor is a relatively common and familial movement disorder presenting with an action tremor that can be reduced by alcohol intake. Although it is usually treated with beta-blockers such as propranolol, it can also be treated with second-line agents such as primidone in those intolerant to beta-blockers. Propranolol is a beta-blocker that can be used to treat essential tremor, such as is seen in this patient. However, the patient's asthma could be exacerbated by this drug, and so propranolol should not be used at this time.

30-y/o presents with loss of libido, galactorrhea, and irregular menses; PE: bitemporal hemianopia; W/U: negative beta human chorionic gonadotropin (β-hCG).

Prolactinoma

A 59-year-old man comes to clinic with complaints of "shakiness" in his hands. His tremor is most noticeable when he is holding something or writing, and is more prominent in his hand than in his shoulder. He has noticed that it seems better with alcohol. . On examination there is a very definite tremor while he unbuttons his shirt. His gait is normal and there is no resting tremor. He has a previous history of asthma. Which of the following medications would be the best choice for this patient? A. Propranolol B. Amantadine C. Primidone D. Lorazepam E. Levodopa/carbidopa

Propranolol Essential tremor is a relatively common and familial movement disorder presenting with an action tremor that can be reduced by alcohol intake. It is usually treated with beta-blockers such as propranolol.

24 yo M is brought to the ER in a drowsy state. His wife reports that he was working at home when he suddenly stiffened, fell backward, and lost consciousness. While he was lying on the ground, he was noted to have no respiration for about one minute, followed by jerking of all four limbs for about five minutes. He was unconscious for another five minutes. VS: T 37°C (98.2°F), P 90, BP 120/80, RR 12 Gen: NAD Lungs: WNL CV: WNL Abd: WNL Ext: WNL Neuro: In a state of confusion and lethargy but oriented; no focal neurologic deficits

Protect the airway Treat the underlying cause if known Primary items: phenytoin, fosphenytoin, or valproate are 1st line therapy. Lamotrigine or topiramate are adjunctive therapy Secondary items: Same as for partial

A 36-year-old man comes to the clinic because of progressively more severe episodes of uncontrolled crying and laughing. In addition, the patient has developed progressive cognitive decline. Physical examination shows the patient has a mild tremor, occasionally jerks the upper extremities and displays a hyperkinetic gait. An MRI is performed. Which of the following best describes the pathology that is present? A. Association with HLA-DR2 genotype B. Cortical atrophy of the parietal/temporal lobe region C. Cytoplasmic accumulations of tau proteins D. Degeneration of the nigrostriatal dopaminergic neurons E. Proteins which have abnormal number of glutamine residues

Proteins which have abnormal number of glutamine Atrophy of the caudate nucleus is the classic MRI finding of Huntington disease (HD). HD is due to accumulation of trinucleotide (CAG) repeats which cause the formation of abnormal proteins (huntingtin).

A 65-year-old woman presents to the emergency department with meaningless speech. The patient was in her usual state of health until 3 hours prior to presentation, where her daughter noticed her mother having "strange speech." On physical examination, her speech is fluent, has paraphasic errors, and comprehension and repetition is impaired. On visual field testing there is a right upper quadrant field-cut.

Wernicke aphasia

The use of anticoagulation is clearly effective in preventing recurrent cardioembolic strokes from atrial fibrillation, a recent myocardial infarction, valvular disease, or a patent foramen ovale. Contraindications to the use of anticoagulation include which of the following? A. hemorrhage on CT scan B. large cerebral infarctions C. evidence of bacterial endocarditis D. a and b E. all of the above

a and b

Tufts of tau protein in _________ are considered diagnostic for progressive supranuclear palsy.

astrocytes

Rupture of an _______________ plaque can cause a thromboembolic ischemic stroke.

atherosclerotic

60 yo M was found unconscious by his wife, who called the paramedics. She left him in bed at 7 A.M. to go to her volunteer job. When she returned for lunch at 1 P.M., she found an empty bottle of amitriptyline next to him. When paramedics arrived, he was noted to be in respiratory distress and was transferred to the ER VS: T 38°C (101°F), P 110, BP 95/45, RR 35, O2 sat 89% on 100% face mask Gen: Acute distress; shallow, rapid breathing HEENT: Dilated pupils Lungs: WNL CV: Tachycardia Abd: WNL Neuro: Opens eyes to painful stimuli Limited PE

TCA Overdose

Treatment of previous embolic stroke includes treatment of predisposing conditions such as ___________ _____________.

atrial fibrillation

Levodopa is always given in combination with ____________in Parkinson patients.

carbidopa

A 50 y/o male patient aching sensation in his legs with uncomfortable deep crawling typically at night when he gets into bed.Also having severe urge to move his legs and wake up several times at night. He denies no low back pain. What is the probable diagnosis ? a. Peripheral neuropathy b. Restless leg syndrome C. peripheral arterial disease D. Lumbar radiculopathy

Restless leg syndrome

A 55-year-old right-hand dominant man presents with a 4-hour history of weakness and tingling of his right hand and numbness of the right side of his mouth. Mild difficulty was noted with word finding. His symptoms have improved since onset but have not fully resolved. There is no significant medical history. Physical examination revealed flat right nasolabial fold, subjective numbness of the right hand, right pronator drift, clumsiness of finger tapping on the right hand, increased deep tendon reflexes on the right, as well as a present Babinski. What is the most likely etiology for this patient's problem? A. migraine headache B. peripheral neuropathy C. syncope D. transient ischemic attack E. seizure

Question 4 Explanation: Three key features of a transient ischemic attack include sudden onset and complete reversal of symptoms within 24 hours, usually within 15 minutes. The symptoms are usually in the anatomical distribution of a single blood vessel. This patient's history is not suggestive of migraine or syncope. His physical examination findings do not correlate with peripheral neuropathy or seizure.

A 75-year-old man comes to the clinic with his son because of symptoms of psychosis noticed by his son. He states that his father has been experiencing auditory hallucinations and delusions secondary to dementia associated with his Parkinson disease. He has been on multiple medications to help with dementia and psychosis but his symptoms have worsened. Which one of the following agents would be the best choice to treat his psychosis and dementia in this situation? A. Diazepam B. Haloperidol C. Memantine D. Olanzapine E. Quetiapine

Quetiapine Although there is no cure for Parkinson disease, symptomatic relief can be treated with multiple agents that act to increase dopamine in the brain. Quetiapine is an antipsychotic agent that does not interfere with dopamine receptors in the brain.

A 17 yo male patient is rushed into your office following a ATV accident. Patient is seizing with suspected hemorrhaging in the brain. A CT angiography is done and shows a large tangle of blood vessels in the left frontal side of his brain. What is the most effective treatment for this patient? a. Clipping of the vessel b. Surgery done with burr holes c. Radiation will likely be sufficient d. Radiation, endovascular embolization, and surgery would be the most effective treatment

Radiation, endovascular embolization, and surgery would be the most effective treatment

A 33-year-old woman comes to the clinic for evaluation of facial weakness. Earlier in the morning, she had trouble drinking coffee as it was drooling from the right side of her face. Her partner mentioned that her face was drooping, and she noticed that she could not move her mouth or eyebrows on that side. She has not had hearing loss, ringing sensation in the ears, or difficulty walking. She underwent a right superficial parotidectomy for the resection of a pleomorphic adenoma in the parotid gland two days ago. Vitals are within normal limits. Physical examination shows asymmetry of the face with smiling. There is also loss of the right nasolabial fold, with drooping of the eyelids and lips on the right side. The rest of the examination is noncontributory. Which of the following is the most likely cause of the findings seen in this patient? A) Tick borne illness B) Reactivation of dormant virus C) Tumor of cerebellopontine angle D) UMN lesion targeting cranial nerve E) Recent surgery

Recent surgery

30-y/o woman with insidious onset of diplopia, scanning speech, paresthesias, and numbness of right upper extremity and urinary incontinence; W/U: MRI shows discrete areas of periventricular demyelination and CSF analysis is positive for oligoclonal bands. (Goal is to alleviate anemia)

Reduce paraprotein Consider erythropoietin or transfusion if severely symptomatic

30-y/o woman with insidious onset of diplopia, scanning speech, paresthesias, and numbness of right upper extremity and urinary incontinence; W/U: MRI shows discrete areas of periventricular demyelination and CSF analysis is positive for oligoclonal bands. (Goal is to prevent renal failure)

Reduce paraprotein. Prevent hypercalcemia, dehydration

A 45-year-old man presents with initiation-type insomnia. He complains of uncomfortable sensations in his legs that are difficult to characterize, which prevent him from falling asleep. He describes these dysesthesias as creeping, crawling, tingling, cramping, or aching of the extremities that are worse during the evening, at rest, or during inactivity. Moving the extremities temporarily improves the symptoms, but together the movements and symptoms delay the onset of sleep and lead to excessive daytime sleepiness the next day.

Restless Leg Syndrome

A 72-year-old woman comes to the emergency department with her son because he believes she suffered an ischemic stroke the night before. Physical examination shows left-sided spastic hemiplegia with hyperreflexia and Babinski sign. Sensation is intact throughout the body. Her right eye is turned down-and-out while the left side of her face is paralyzed below the eye. Tests of the pupillary light reflex show direct and consensual responses by the the right pupil and the left pupil is unresponsive and fixed. Which of the following is the most likely location of the lesion? A. Left sensory cortex B. Left thalamus C. Right midbrain D. Right thalamus E. Superior cervical ganglion

Right midbrain Stroke symptoms of spastic hemiplegia, hyperreflexia, and Babinski sign indicate an upper motor neuron lesion. Muscles of facial expression located below the eye receive innervation from only the contralateral cerebral cortex, and those above the eye receive innervation from both sides of the cortex.

55-y/o man presents with lower extremity weakness and muscle atrophy; PE: positive Babinski reflex, upper extremity hyperreflexia, and spasticity.

Riluzole, a presumed glutamate antagonist, is the only FDA-approved medication for ALS. Improves survival by approximately six months Noninvasive positive-pressure ventilation improves survival and should be offered if FVC falls to < 50% predicted. Percutaneous endoscopic gastrostomy tube placement allows for ↑ nutrition in the face of dysphagia and leads to ↑ muscle mass and longer survival.

A 55-year-old woman presents to the emergency department with a headache. She states that she felt a bad headache come on this morning while she was gardening and carrying heavy pots, and it has not been improving. The patient has a past medical history of hypertension and diabetes which is currently being treated by her primary care physician. Her blood pressure is 157/99 mmHg. Which of the following is the best explanation for the most likely diagnosis? A. Abnormal vascular tone in the CNS B. Dehydration and stress C. Hypersensitivity of the trigeminal nerve D. Muscular pain and strain E. Rupture of a berry aneurysm

Rupture of a berry aneurysm This patient is presenting with a sudden headache and blood in the subarachnoid space on head CT suggesting a diagnosis of subarachnoid hemorrhage (SAH), which commonly results from rupture of a berry aneurysm. SAH typically presents with a sudden onset "thunderclap" headache that is often described as the "worst headache of my life." Hypertension is a common risk factor. The diagnosis should be quickly confirmed with a non-contrast head CT. If the head CT is negative but SAH is still suspected, a lumbar puncture can help confirm the diagnosis (demonstrating xanthochromia). Patients should be referred to neurosurgery once the diagnosis is confirmed.

A 47-year-old male with a medical history significant for hypertension, recurrent urinary tract infections, mitral valve prolapse, and diverticulosis experiences a sudden, severe headache while watching television on his couch. He calls 911 and reports to paramedics that he feels as if "someone shot me in the back of my head." He is rushed to the emergency room. On exam, he shows no focal neurological deficits but has significant nuchal rigidity and photophobia.

SAH

A 50-year-old woman is brought to the emergency center after experiencing the sudden onset of severe headache associated with vomiting, neck stiffness, and left-sided weakness. She was noted to complain of the worst headache of her life shortly before she became progressively confused. Two weeks ago, she returned from jogging noting a moderate headache with nausea and photophobia. She has a history of hypertension and tobacco use. On examination, her temperature is 37.6°C (99.8°F); heart rate, 120 beats/min; respiration rate, 32 breaths/min; and blood pressure, 180/90 mmHg. She is stuporous and moaning incoherently. Her right pupil is dilated with papilledema and ipsilateral ptosis, and she vomits when a light is shone in her eyes. She has a left lower face droop and does not withdraw her left arm and leg to pain as briskly compared to the right. Her neck is rigid. Her chest examination reveals tachycardia and bibasilar crackles. During the examination, her head suddenly turns to the left, and she exhibits generalized tonic-clonic activity. STAT laboratory tests show a sodium level of 125 mEq/L. The electrocardiograph (ECG) shows broad, deeply inverted T-waves and a prolonged QT interval.

SAH

A 53-year-old black woman complains of a sudden, excruciating headache while sitting at work. The headache is diffuse, intense, and accompanied by nausea and vomiting. She describes the headache as the worst headache of her life. She loses consciousness following onset of the headache and is on the floor for less than 1 minute. She is being treated for hypertension and is a smoker. On examination she has a normal mental state, meningismus, bilateral subhyaloid hemorrhages, and right third cranial nerve palsy. There are no sensory deficits or weakness. Brain CT reveals diffuse subarachnoid blood in basal cisterns and sulci.

SAH

45-y/o presents with the gradual onset of sharp pain radiating from his buttocks down his leg that began 2 weeks ago when he began to lift a heavy box; PE: positive straight leg raise test

Sciatica

________________ and rasagiline are two monoamine oxidase-B inhibitors that can be used alone as initial treatment of Parkinson disease; or, as an adjunct alongside levodopa.

Selegiline

55-y/o with a h/o squamous cell carcinoma of the lung presents with nausea, vomiting, headache, and diplopia; PE: papilledema, left oculomotor palsy, right pronator drift; MRI: multiple round, hyperintense cortical and cerebellar lesions.

Solitary items: surgical resection followed by whole brain radiotherapy. Consider stereotactic radiosurgery or gamma-knife radiotherapy Multiple items: whole brain radiotherapy

A 17 year old female came to the clinic with an upper motor neuron lesion would exhibit which of the following findings? A. Fasciculations B. Areflexia C. Muscular atrophy D. Spasticity

Spasticity

A 58-year-old male presents with difficulties in concentration and worsening insomnia. These symptoms have been progressively worsening over the past month. Startle myoclonus is appreciated on physical examination. Electroencephalography shows biphasic sharp wave patterns.

Spongiform Encephalopathy / Creutzfeldt-Jakob Disease

75 y/o female is brought into the ED with numbness and weakness on the left side of her body. She appears confused and has trouble speaking. Her family says she started displaying symptoms around 1 hr previously. Her HR is 87, BP is 187/102, and temperature is 97.9. What would not be indicated as the next treatment step? a. Start IV tPA b. Administer CCB/ BB c. Check her glucose levels d. Consult with a neurologist to evaluate the case

Start IV tPA

A 45-year-old homeless man is found unconscious in the street. He appears stiff, with continuously shaking extremities, foaming at the mouth, and urinary incontinence. On arrival to the emergency department, he has stopped shaking but is still unconscious. Stiffening and shaking resume a few minutes later. Two empty medication bottles are found in his pocket, labeled phenytoin and valproic acid.

Status Epilepticus

A 72-year-old man presents to the emergency department with acute onset of right-sided weakness. The patient was eating breakfast when he suddenly lost strength in the right side of his body such that he was unable to move his right arm or leg. He also noted a loss of sensation in the right arm and leg and difficulty speaking. His wife called 911, and he was brought to the emergency department. His medical history is remarkable for long-standing hypertension, hypercholesterolemia, and recently diagnosed coronary artery disease. On physical examination, his blood pressure is 190/100 mm Hg. Neurologic examination is notable for right facial droop and a dense right hemiparesis. The Babinski reflex is present on the right. CT scan of the brain shows no evidence of hemorrhage. He is admitted to the neurologic ICU.

Stroke

Sarah, a 25 y/o F, was brought to the ER by her mom after saying she got a HA that was strongest at onset and caused her to vomit, shortly followed by loss of consciousness. Her mom states she was just coming home from a long day at school and sat down to turn on the TV when this happened. Imaging is shown below. What was she diagnosed with? A. Partial Complex Seizure B. Migraine C. Subarachnoid Hemorrhage D. Epidural Hemorrhage

Subarachnoid Hemorrhage

50-y/o with h/o polycystic kidney disease presents with "worst headache of life," photophobia, nausea; PE: right eye deviated down and out; W/U: CSF is xanthrochromic.

Subarachnoid Hemorrhage from Ruptured Berry Aneurysm

A 58-year-old woman presents to the emergency department with a severe headache of sudden onset. The headache occurred immediately while at rest, and she describes the headache as the most severe she has ever had. Her headache symptoms are also accompanied by photophobia. She has tried ibuprofen and sumatriptan, but it has not improved her symptoms. Medical history is significant for migraine headache, hypertension, cigarette smoking, and alcohol use disorder. Physical examination is notable for nuchal rigidity. A non-contrast head CT is shown.

Subarachnoid hemorrhage

A 35-year-old male comes to the emergency department because of a stiff neck and vomiting. He states that these symptoms developed suddenly, while he was out for his daily run. Medical history is noncontributory. His temperature is 37.3°C (99°F), pulse is 87/min, respirations are 18/min, and blood pressure is 117/78 mm Hg. Examination shows a fit appearing man. A non-contrast CT-scan is obtained. Which of the following is the most likely diagnosis? A. Contusion B. Epidural hematoma C. Subarachnoid hemorrhage D. Subdural hematoma E. Meningitis

Subarachnoid hemorrhage Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space, the area between the arachnoid membrane and the pia mater surrounding the brain. While SAH commonly occurs in older people, it can affect people of any age.

A. 47-year-old woman presents to the emergency room with a stiff neck, photophobia, and an extremely severe headache that began while she was at the meet and greet social after Sunday church service . She states her symptoms came on immediately and she is in severe distress. What is the most likely diagnosis? A. Thrombotic Stroke B. Embolic Stroke C. Subararchnoid Hemorrhage D. Intracerebral Hemorrhage

Subararchnoid Hemorrhage

32-y/o man with h/o Arnold-Chiari malformation presents with bilateral upper extremity muscle weakness; PE: loss of pain and temperature sensation, ↓ DTR in upper extremities and scoliosis; MRI shows central cavitation of the thoracic spinal cord.

Suboccipital craniectomy and upper cervical laminectomy, with the aim of decompressing the malformation at the foramen magnum. The cord cavity should be drained, and if necessary an outlet for the fourth ventricle can be made. In cavitation associated with intramedullary tumor, treatment is surgical, but radiation therapy may be necessary if complete removal is not possible. Posttraumatic items are also treated surgically if they lead to increasing neurologic deficits or to intolerable pain

32-y/o man with h/o Arnold-Chiari malformation presents with bilateral upper extremity muscle weakness; PE: loss of pain and temperature sensation, ↓ DTR in upper extremities and scoliosis; MRI shows central cavitation of the thoracic spinal cord.

Syringomyelia

65-y/o presents with a gradual decline in memory and inability to complete activities of daily living; W/U: CT shows marked enlargement of ventricles and diffuse cortical atrophy.

Supportive therapy for the patient and family Cholinesterase inhibitors (Donepezil, rivastigmine, and galantamine) are first line therapy Vitamin E

84 yo F brought in by her son complains of forgetfulness (e.g., forgets phone numbers, loses her way home) along with difficulty performing some of her daily activities (e.g., bathing, dressing, managing money, answering the phone). The problem has gradually progressed over the past few years. VS: P 90, BP 120/60, RR 12 Gen: NAD Lungs: WNL CV: WNL Abd: WNL Ext: WNL Neuro: On mini-mental status exam, patient cannot recall objects, follow three-step commands, or spell "world" backward; cranial nerves intact; strength and sensation intact

Supportive therapy for the patient and family Cholinesterase inhibitors (Donepezil, rivastigmine, and galantamine) are first line therapy Vitamin E

75-y/o alcoholic man on warfarin for h/o atrial fibrillation presents with declining mental status, headache, and papilledema; CT shows crescenteric, hypodense, 2 cm fluid collection along convexity.

Surgical blood evacuation or if the item is increasing in size

65-y/o woman with h/o spinal metastases from breast cancer presents with pain radiating down the back of her leg, saddle anesthesia, urinary retention; PE: absent ankle jerk reflexes; W/U: CT shows large bony fragment in lumbar spinal canal.

Surgical evaluation LBP is treated with NSAIDs and physiotherapy. Heavy lifting should be avoided.

65-y/o woman with h/o neurofibromatosis type 2 presents with headache, right-sided leg jerking, and worsening mental status; PE: papilledema and right-sided pronator drift; W/U: CT scan shows dural-based, enhancing, left-sided softball-sized tumor.

Surgical excision for large items Serial scan observation for small items

29 yo F presents with daily episodes of bilateral bandlike throbbing pain in her frontal-occipital region that last between 30 minutes and a few hours. She usually experiences these episodes when she is either tired or under stress. She denies any associated nausea, vomiting, phonophobia, photophobia, or aura. She also feels pain and stiffness in her neck and shoulder. VS: Afebrile, P 70, BP 120/80, RR 15 Gen: NAD Lungs: WNL CV: WNL Abd: WNL Ext: WNL Neuro: WNL

Tension Headache

A 37-year-old woman presents with a 12-year history of episodic headaches. She experiences these 4 times a week, typically beginning at the end of a workday. The pain is generalized and described as similar to wearing a tight band around her head. The headaches are bothersome, but not disabling, and she denies any nausea or vomiting. She is slightly sensitive to noise but has no photophobia. Pain during her attacks typically responds to ibuprofen. Examination reveals tenderness of her scalp and both trapezius muscles.

Tension Headache

A 56-year-old man presents with a 25-year history of constant headache. The onset was insidious and he is quite certain that the only time he is headache-free is when he sleeps. He states the headache is generalized and his neck and shoulders are always "tight". He denies any associated autonomic symptoms including eye tearing, nasal congestion, light and sound sensitivity, nausea, or vomiting.

Tension Headache

______________ and reserpine are medications used to treat chorea in Huntington disease by inhibiting vesicular monoamine transporter, a monoamine transporter protein which guides dopamine to the synapse.

Tetrabenazine

A 31-year-old presents with self-described complaints of being "fidgety and irritable" that is unlike his "calm personality a few years ago". What is concerning to him is that his father was diagnosed with a similar condition at the age of 38. His father began a progressive decline - losing interest in his life and family, becoming messy, experiencing involuntary movements, and worsening dementia as he grew older. Genetic tests were performed on the patient which confirmed that he has a larger number of repeats than his father. He is concerned that the disease may begin earlier for him or may have already started. Which of the following trinucleotide repeats is found in this disease?

The above presentation of the father with progressive dementia, chorea, and losing interest in his life suggests that the father may have Huntington's disease (HD), which is caused by CAG trinucleotide repeats.

A 38-year-old man with mental retardation (IQ 50), facial features that include epicanthic folds and low-set small ears, and hands pictured in Figure A, is brought in by his elderly parents, who provide constant care. They are concerned that over the past 3 years, he has become increasingly forgetful and less interested in conversing and sharing his thoughts. If a post-mortem brain autopsy were conducted, the most likely histopathological feature in his brain underlying these changes would be:

The clinical presentation is consistent with Alzheimer's disease in a patient with Down syndrome (trisomy 21). On brain autopsy, the hallmark histopathological changes of Alzheimer's disease are extracellular beta-amyloid plaques and intracellular aggregates of phosphorylated tau (neurofibrillary tangles).

A 28-year-old female presents to her primary care doctor complaining of new onset blurry vision. She first noticed her vision getting blurry toward the end of the day several days ago. Since then, she reports that her vision has been fine when she wakes up but gets worse throughout the day. She has also noticed that her eyelids have started to droop before she goes to bed. On exam, she has bilateral ptosis that is worse on the right. Administering edrophonium to this patient leads to an immediate improvement in her symptoms. Which of the following is most likely true about this patient's condition?

The most likely diagnosis for this patient is myasthenia gravis (MG). MG is associated with the development of a thymoma and thymectomy can therefore lead to an improvement in symptoms in some patients.

A 5-year-old patient is brought to the emergency department by his parents for concerning behavior. His parents relate that over the past 3 weeks, he has had multiple episodes of staring into space, lip smacking, and clasping his hands together. The patient has his eyes open during these episode but does not respond to his parents' voice or his name. These episodes last between 1-2 minutes after which the patient appears to return back to awareness. The patient is confused after these episodes and appears not to know where he is for about 15 minutes. These episodes occur once every few days and the most recent one happened about 10 minutes before the patient arrived to the emergency department. On arrival, the patient is mildly confused and does not know where he is or what recently happened. He is slow to respond to questions and appears tired. Which of the following is the most likely diagnosis in this patient?

The patient displays loss of consciousness/awareness with motor automatisms like lip-smacking and hand-clasping characteristic of a complex partial seizure.

A 79-year-old man with a long-standing history of hypertension and diabetes presents to the emergency department with sudden-onset of loss of motor function on the left side of his body. Neurologic exam shows normal sensation throughout the body. MRI of the brain is obtained and shows a small sub-cortical infarct involving a perforating vessel. Which of the following is the most likely underlying pathogenesis?

This patient has a lacunar infarct, which is most often caused by lipohyalinosis of small perforating vessels predisposing to occlusion.

A 48-year-old man presents to the ER with a sudden-onset, severe headache. He is vomiting and appears confused. His wife, who accompanied him, says that he has not had any trauma, and that the patient has no relevant family history. He undergoes a non-contrast head CT that shows blood between the arachnoid and pia mater. What is the most likely complication from this condition?

The patient has had a subarachnoid hemorrhage (SAH), and arterial vasospasm is the most common complication from this disease.

A 25-year-old male rugby player presents to the emergency room complaining of a severe headache. He is accompanied by his teammate who reports that he had a head-to-head collision with another player and briefly passed out before regaining consciousness. His past medical history is significant for a pilocytic astrocytoma as a child treated successfully with surgery. His family history is notable for stroke in his father. His temperature is 98.9°F (37.2°C), blood pressure is 160/90 mmHg, pulse is 60/min, and respirations are 20/min. On examination, he is lethargic but oriented to person, place, and time.

The patient in this vignette presents with a post-traumatic headache preceded by a momentary loss of consciousness, a scenario that is suggestive of epidural hematoma. Rupture of the middle meningeal artery, a branch of the maxillary artery, leads to the development of an epidural hematoma.

A 59-year-old male presents to his primary care physician complaining of muscle weakness. Approximately 6 months ago, he started to develop gradually worsening right arm weakness that progressed to difficulty walking about three months ago. His past medical history is notable for a transient ischemic attack, hypertension, hyperlipidemia, and diabetes mellitus. He takes aspirin, lisinopril, atorvastatin, metformin, and glyburide. He does not smoke and he drinks alcohol occasionally. Physical examination reveals 4/5 strength in right shoulder abduction and right arm flexion. A tremor is noted in the right hand. Strength is 5/5 throughout the left upper extremity. Patellar reflexes are 3+ bilaterally. Sensation to touch and vibration is intact in the bilateral upper and lower extremities. Tongue fasciculations are noted. Which of the following is the most appropriate treatment in this patient?

The patient in this vignette presents with asymmetric limb weakness suggestive of amyotrophic lateral sclerosis (ALS). The only medication known to slow the progression of ALS is riluzole.

A 62-year-old man is brought to his primary care physician by his wife who is concerned about the patient's frequent falls. Approximately 6 months ago, she started noticing that he was walking more slowly than usual. He has fallen more than 6 times in the past month, and she is worried that he will sustain a serious injury if he does not stop falling. The patient is a retired banking executive and was active as a triathlete until the age of 60. He does not smoke and drinks 2-3 alcoholic beverages per day. His family history is notable for normal pressure hydrocephalus in his mother and Alzheimer dementia in his father. His temperature is 97.8°F (36.6°C), blood pressure is 131/81 mmHg, pulse is 68/min, and respirations are 19/min. On exam, his movements appear slowed and forced. He shuffles his feet when he walks. Tone is increased in his upper and lower extremities bilaterally. This patient's condition is most strongly associated with which of the following histologic findings on brain autopsy?

The patient in this vignette presents with bradykinesia, frequent falls, a shuffling gait, and muscle rigidity suggestive of Parkinson disease (PD). PD is characterized by Lewy bodies (round eosinophilic inclusions of α-synuclein).

A 61-year-old woman presents to her primary care doctor with her son who reports that his mother is not acting like herself. She has gotten lost while driving several times in the past 2 months and appears to be talking to herself frequently. Of note, the patient's husband died from a stroke 4 months ago. The patient reports feeling sad and guilty for causing so much trouble for her son. Her appetite has decreased since her husband died. On examination, she is oriented to person, place, and time. She is inattentive, and her speech is disorganized. She shakes her hand throughout the exam without realizing it. Her gait is slow and appears unstable. This patient's condition would most likely benefit from which of the following medications?

The patient in this vignette presents with dementia and parkinsonism suggestive of Lewy body dementia (LBD). The first-line treatment for LBD involves anti-cholinesterase inhibitors (e.g., rivastigmine or donepezil).

A 26-year-old man presents to his primary doctor with one week of increasing weakness. He reports that he first noticed difficulty walking while attending his sister's graduation last week, and yesterday he had difficulty taking his coffee cup out of the microwave. He remembers having nausea and vomiting a few weeks prior, but other than that has no significant medical history. On exam, he has decreased reflexes in his bilateral upper and lower extremities, with intact sensation. If a lumbar puncture is performed, which of the following results are most likely?

The patient's clinical presentation is most consistent with Guillain-Barre syndrome. Cerebrospinal fluid (CSF) analysis in this syndrome is notable for "albuminocytologic dissociation," meaning that there is increased protein with a normal cell count, glucose, and opening pressure.

A 73-year-old man presents to his primary care doctor with his son who reports that his father has been acting strangely. He has started staring into space throughout the day and has a limited attention span. He has been found talking to himself on several occasions and has gotten lost while driving twice. He has occasional urinary incontinence. His past medical history is notable for a stroke 5 years ago with residual right arm weakness, diabetes, hypertension, and hyperlipidemia. He takes aspirin, glyburide, metformin, lisinopril, hydrochlorothiazide, and atorvastatin. On examination, he is oriented to person and place but thinks the year is 1989. He is inattentive throughout the exam. He takes short steps while walking. His movements are grossly slowed. A brain biopsy in this patient would most likely reveal which of the following?

The patient in this vignette presents with impaired cognition, inattention, hallucinations, and Parkinsonian symptoms suggestive of Lewy body dementia (LBD). Eosinophilic intracytoplasmic inclusions represent clumps of alpha-synuclein protein that can be found in the brains of patients with LBD.

A 32-year-old man presents to his primary care provider with right leg weakness and numbness. He reports a 2-day history of "clumsiness" in his right lower extremity after playing in his company's annual weekend-long charity baseball tournament. He says a similar episode happened 1 year ago during the same tournament. He has a history of major depressive disorder and right distal radius fracture status post-closed reduction and casting after falling 2 years ago. He takes fluoxetine. He also reports that he several years ago he had an isolated episode of decreased vision and inability to move his right eye that resolved on its own. He has a 15-pack-year smoking history and drinks 3-4 beers per week. His temperature is 98.4°F (36.9°C), blood pressure is 115/65 mmHg, pulse is 85/min, and respirations are 18/min. On exam, hip flexion, knee extension, and ankle dorsiflexion are all 3/5 on his right and 5/5 on his left. Right Achilles and patellar reflexes are 1+ on the right and 2+ on the left. He has decreased sensation to light touch throughout the right leg especially below the knee. Additional questioning would most likely reveal which of the following additional features about this patient's current symptoms?

The patient in this vignette presents with unilateral lower extremity numbness and weakness with a history of similar prior episodes suggestive of a multiple sclerosis (MS) flare. MS symptoms can often be exacerbated in the heat.

A 65-year-old patient with a history of atrial fibrillation presents to the emergency room complaining of sudden-onset speech difficulty. Her husband notes that they were eating dinner earlier in the night, when he suddenly noticed the change. On admission, her blood pressure is 135/80 mmHg, heart rate is 85 beats per minute, temperature is 98.6 degrees Fahrenheit, and SpO2 is 99% on room air. Her MRI is shown below in Figure A. Which of the following speech deficit is the patient most likely to experience?

The patient presents with a left posterior frontal lobe infarct in the territory of Broca's area, which is associated with difficulty with speech production and repetition.

A 53-year-old man is brought by his daughter to the clinic. She lives a town away but visits often. She reports that on recent visits, his mood has been volatile, ranging from aggressive at some moments to depressed at others. She has noticed some new jerky movements which she has never seen before and has been quite forgetful. She is concerned that he might be abusing alcohol and drugs. What changes would you expect in the brain of this patient?

The patient presents with signs and symptoms of Huntington disease. This condition is marked by a decrease in GABA at the caudate nucleus.

A 71 year-old female is brought to the emergency room by her husband. The husband reports that they were taking a walk together one hour ago, when his wife experienced sudden, right arm and leg weakness. He noticed that she had slurred speech, and that she was not able to tell him where she was. The patient underwent an emergent CT scan, which was unremarkable, and was treated with tissue plasminogen activator (tPA). Which of the following EKG findings increases a patient's risk for this acute presentation?

The patient's presentation is most consistent with an acute ischemic stroke, which is associated with atrial fibrillation.

A 70-year-old man is brought to the emergency department because of left-sided weakness. The weakness began an hour ago, while at home, when he noticed that he was suddenly unable to move his left leg. Medical history is contributory for hypercholesterolemia, hypertension, and tobacco-dependence. Physical examination shows 0/5 strength in the left lower extremity and 5/5 strength in the left upper extremity. The left leg and foot also have decreased sensation. A CT scan of the brain shows no hemorrhage. Which of the following arteries is most likely affected by this patient's condition? Internal thoracic artery Lenticulostriate arteries Middle cerebral artery Posterior inferior cerebellar artery Right anterior cerebral artery

The right anterior cerebral artery is the blood supply to the right medial parietal lobe of the brain, and an ischemic stroke here leads to left-leg weakness and sensation deficit.

4768) A 4-year-old previously healthy male presents with 4 days of intermittent vomiting and 5-6 daily loose stools. His mother noted bloody stools and decreased oral intake of food and water over the last 24 hours. He is normally in daycare; however, he has been home for the past 3 days. On physical exam his temperature is 102.2°F (39°C), blood pressure is 140/90 mmHg, pulse is 120/min, respirations are 22/min and O2 saturation is 99% on room air. He has dry mucous membranes. On abdominal exam you note diffuse tenderness to palpation without rebound or guarding. There are no masses, hepatosplenomegaly, and bowel sounds are hyperactive. Ultrasound of the right lower quadrant is negative for appendicitis. Stool is guaiac positive. He receives 15mg/kg acetaminophen and fluids are started. The next day, he complains of lower extremity weakness and tingling. On repeat exam, lower extremity strength is 3/5 with diminished patellar deep tendon reflexes. Which of the following lab findings would most likely be seen in this patient?

This child with diarrhea and fever followed by lower extremity weakness and hyporeflexia has Guillain-Barre syndrome (GBS) after gastrointestinal illness. Cerebrospinal fluid (CSF) will show increased cerebrospinal fluid protein with normal cell count (albuminocytologic dissociation).

A 25-year-old man with no significant past medical history is brought in by ambulance after a witnessed seizure at home. On physical exam, temperature is 102.3 deg F (39.1 deg C), blood pressure is 90/62 mmHg, pulse is 118/min, and respirations are 25/min. He is unable to touch his chin to his chest and spontaneously flexes his hips with passive neck flexion. Appropriate empiric treatment is begun. CT head is unremarkable, and a lumbar puncture sample is obtained. Gram stain of the cerebrospinal fluid (CSF) reveals gram-positive diplococci. Which of the following would you expect to see on CSF studies?

This clinical presentation is consistent with bacterial meningitis, likely due to Streptococcus pneumoniae (given gram-positive diplococci). Cerebrospinal fluid (CSF) studies in bacterial meningitis typically show elevated opening pressure, elevated protein, and low glucose.

An 81-year-old woman presents to your office accompanied by her husband. She has been doing well except for occasional word finding difficulty. Her husband is concerned that her memory is worsening over the past year. Recently, she got lost twice on her way home from her daughter's house, was unable to remember her neighbor's name, and could not pay the bills like she usually did. She has a history of hypertension and arthritis. She has no significant family history. Her medications include a daily multivitamin, hydrochlorothiazide, and ibuprofen as needed. Physical exam is unremarkable. Which of the following is associated with an increased risk of this patient's disease?

This elderly woman presenting with memory loss, word-finding difficulty, and getting lost in familiar places most likely has Alzheimer's disease. ApoE4 is associated with an increased risk of sporadic Alzheimer's disease.

A 72-year-old man with longstanding history of diabetes mellitus and hypertension presents to the emergency department with sudden-onset numbness. On your neurological exam, you note that he has loss of sensation on the left side of his face, arm, and leg. His motor strength exam is normal, as are his cranial nerves. Which of the following is the most likely explanation for his presentation?

This patient had a stroke with total sensory loss, consistent with thalamic stroke.

A 59-year-old woman with a past medical history of atrial fibrillation currently on warfarin presents to the emergency department for acute onset dizziness. She was watching TV in the living room when she suddenly felt the room spin around her as she was getting up to go to the bathroom. She denies any fever, weight loss, chest pain, palpitations, shortness of breath, lightheadedness, or pain but reports difficulty walking and hiccups. A physical examination is significant for rotary nystagmus and decreased pin prick sensation throughout her left side. A magnetic resonance image (MRI) of the head is obtained and shows ischemic changes of the right lateral medulla. What other symptoms would you expect to find in this patient?

This patient has lateral medullary (Wallenberg) syndrome as demonstrated by her vertigo, rotary nystagmus, and decreased pain sensation in the setting of ischemic changes in the lateral medulla on MRI. Other symptoms characteristic of lateral medullary syndrome include decreased gag reflex.

A patient is transferred from an outside hospital by family request. The patient is a 76-year-old gentleman who developed acute onset left-sided weakness four days ago with the imaging findings seen in Figure A. Despite aggressive care, the patient dies shortly after transfer. The family requests an autopsy. What histological finding would you expect to find on evaluation of the patient's brain?

This patient is 4 days removed from a large ischemic stroke. At this point in time the predominant histological finding would be macrophage infiltration and phagocytosis.

A 73-year-old man presents to your office accompanied by his wife. He has been experiencing a tremor in his right hand for the last several months that seems to be worsening. He does not have any other complaints and says he's "fine." His wife thinks that he has also had more difficulty walking. His history is significant for hypertension and an ischemic stroke of the right middle cerebral artery 2 years ago. His medications include hydrochlorothiazide and daily aspirin. On physical exam you note that the patient speaks with a soft voice and has decreased facial expressions. He has a resting tremor that is worse on the right side. He has increased resistance to passive movement when you flex and extend his relaxed wrist. He has 5/5 strength bilaterally. Neuronal degeneration in which of the following locations is most likely responsible for the progression of this disease?

This patient presenting with a resting tremor, decreased expression, and rigidity most likely has Parkinson's disease. Parkinson's disease is a degenerative that is associated with neuronal degeneration in the substantia nigra pars compacta.

A 65-year-old man presents to the emergency department for a loss of vision. He was outside gardening when he suddenly lost vision in his right eye. He then immediately called emergency medical services, but by the time they arrived, the episode had resolved. Currently, he states that he feels fine. The patient has a past medical history of diabetes and hypertension. Cardiac exam is notable for a systolic murmur along the right sternal border that radiates to the carotids. A CT scan of the head demonstrates mild cerebral atrophy but no other findings. Which of the following is the next best step in management? A. Tissue plasminogen activator B. MRI C. Heparin bridge to warfarin D. Ultrasound of the neck

This patient is presenting with a transient ischemic attack (TIA) that has resolved. After the acute episode, the best next step in management is an ultrasound of the neck. Amaurosis fugax (a type of transient ischemic attack) presents with painless loss of vision from dislodged emboli. By the time these patients present, they often are asymptomatic and the episode has resolved. These patients should still receive a head CT/MRI to rule out any other abnormalities. After the acute episode, the next step in management is to perform ultrasound of the neck to search for plaques, since many emboli can originate at the bifurcation of the carotid.

A 26-year-old man is brought to the emergency department due to right-sided facial and upper extremity weakness and aphasia. The patient was in his usual state of health until two hours prior to presentation, when he was eating breakfast with a friend and acutely developed the aforementioned symptoms. Medical history is unremarkable except for mild palpitations that occur during times of stress or when drinking coffee. Physical examination is consistent with the clinical presentation. Laboratory testing is unremarkable and a 12-lead electrocardiogram is normal. A non-contrast head CT and diffusion-weighted MRI shows no intracranial hemorrhage and an isolated superficial cerebral infarction. Transthoracic echocardiography with agitated saline mixed with air shows microbubbles in the left heart. There is a possible minor effusion surrounding the heart and the ejection fraction is within normal limits. Which of the following is most likely the cause of this patient's clinical presentation?

This patient is presenting with symptoms concerning for an acute stroke and a positive "bubble study", which is most likely due to a patent foramen ovale (PFO) leading to cryptogenic stroke.

A 73-year-old woman is brought in by her daughter stating that her mom has become increasingly forgetful and has trouble remembering recent events. Her memory for remote events is remarkably intact. The patient is no longer able to cook for herself as she frequently leaves the stove on unattended. She has recently been getting lost in her neighborhood even though she has lived there for 30 years. Her mood is not depressed. Decreased activity in which of the following areas of the brain is known to be involved in the pathogenesis of Alzheimer's disease?

This patient likely has Alzheimer's dementia. The pathogenesis of Alzheimer's involves decreased production of acetylcholine caused by decreased activity of choline acetyltransferase in the nucleus basalis of Meynert and hippocampus.

A 65-year-old man presents with difficulty in decision-making and planning, which is of abrupt onset and occurs 3 months after a stroke. He has strong vascular risk factors, including smoking. Over time, there has been a fluctuating stepwise reduction in cognitive function. There is a history of nocturnal confusion and incontinence. On examination there is evidence of focal neurologic deficit with pseudobulbar palsy and extrapyramidal signs. Neuro-imaging indicates a probable vascular etiology with white matter changes and infarction.

Vascular Dementia

A 73-year-old man presents to your office accompanied by his wife. He has been experiencing a tremor in his right hand for the last several months that seems to be worsening. He does not have any other complaints and says he's "fine." His wife thinks that he has also had more difficulty walking. His history is significant for hypertension and an ischemic stroke of the right middle cerebral artery 2 years ago. His medications include hydrochlorothiazide and daily aspirin. On physical exam you note that the patient speaks with a soft voice and has decreased facial expressions. He has a resting tremor that is worse on the right side. He has increased resistance to passive movement when you flex and extend his relaxed wrist. He has 5/5 strength bilaterally. Neuronal degeneration in which of the following locations is most likely responsible for the progression of this disease? Substantia nigra pars compacta Frontotemporal lobe Subthalamic nucleus Caudate and putamen Vermis

This patient presenting with a resting tremor, decreased expression, and rigidity most likely has Parkinson's disease. Parkinson's disease is a degenerative that is associated with neuronal degeneration in the substantia nigra pars compacta.

A 74-year-old African-American woman is brought to the emergency department by her home health aid. The patient was eating breakfast this morning when she suddenly was unable to lift her spoon with her right hand. She attempted to get up from the table, but her right leg felt weak. One hour later in the emergency department, her strength is 0/5 in the right upper and right lower extremities. Strength is normal in her left upper and lower extremities. Sensation is normal bilaterally. An emergency CT of the head does not show signs of hemorrhage. Subsequent brain MRI shows an infarct involving the internal capsule. Which of the following is true about her disease process?

This patient presents with a pure motor stroke, which is one of the stroke syndromes caused by lacunar infarcts. The most important predisposing risk factors for lacunar infarcts are diabetes and hypertension.

A 38-year-old woman presents to her primary care physician for evaluation of 3 months of increasing fatigue. She states that she feels normal in the morning, but that her fatigue gets worse throughout the day. Specifically, she says that her head drops when trying to perform overhead tasks. She also says that she experiences double vision when watching television or reading a book. On physical exam, there is right-sided ptosis after sustaining upward gaze for a 2 minutes. Which of the following treatments may be effective in treating this patient's diagnosis?

This patient who experiences muscle weakness that is worse after repetitive use and develops ptosis on sustained upward gaze most likely has myasthenia gravis, which can be treated with thymectomy if a thymoma is identified.

An 15-year-old boy is brought to the emergency department after he passed out in the hallway. On presentation, he is alert but confused about why he is in the hospital. He says that he remembers seeing flashes of light to his right while walking out of class but cannot recall what happened next. His next memory is being woken up by emergency responders who wheeled him into an ambulance. A friend who was with him at the time says that he seemed to be swallowing repeatedly and staring out into space. He has never had an episode like this before, and his past medical history is unremarkable. Which of the following characteristics is most likely true of the cause of this patient's symptoms?

This patient who saw visual flashes and then lost consciousness while demonstrating automatisms most likely had a complex partial seizure that started in the left occipital lobe and secondarily generalized.

A 23-year-old man presents to the emergency room following a stab wound to the back. He was in a bar when he got into an argument with another man who proceeded to stab him slightly right of the midline of his back. He is otherwise healthy and does not take any medications. He has one previous admission to the hospital for a stab wound to the leg from another bar fight 2 years ago. His temperature is 99°F (37.2°C), blood pressure is 115/80 mmHg, pulse is 100/min, and pulse oximetry is 99% on room air. Cardiopulmonary and abdominal exams are unremarkable; however, he has an abnormal neurologic exam. If this wound entered his spinal cord but did not cross the midline, which of the following would most likely be seen in this patient?

This patient with a right midline stab wound to the back has a hemisection of the spinal cord, or Brown-Sequard syndrome, which would result in ipsilateral flaccid paralysis at the level of the lesion.

A 68-year-old man is brought to the emergency department by ambulance after he was found to be altered at home. Specifically, his wife says that he fell and was unable to get back up while walking to bed. When she approached him, she found that he was unable to move his left leg. His past medical history is significant for hypertension, atrial fibrillation, and diabetes. In addition, he has a 20-pack-year smoking history. On presentation, he is found to still have difficulty moving his left leg though motor function in his left arm is completely intact. The cause of this patient's symptoms most likely occurred in an artery supplying which of the following brain regions?

This patient with acute onset lower extremity weakness most likely experienced a stroke of the anterior cerebral artery, which is the artery that supplies the cingulate gyrus.

An 89-year-old woman is admitted to the neurology intensive care unit following a massive cerebral infarction. She has a history of hypertension, ovarian cancer, and lung cancer. Her medications include lisinopril and aspirin. She has smoked a few cigarettes each day for the last 60 years. She does not drink alcohol or use drugs. An arterial line and intraventricular pressure monitor are placed. You decide to acutely lower intracranial pressure by causing cerebral vasoconstriction. Which of the following methods could be used for this effect?

This patient with cerebral edema can be treated with therapeutic hyperventilation to decrease cerebral blood flow.

A 68-year-old man is brought to the physician by his wife because she is concerned about his speech being irregular. Specifically, she says that over the last 8 months, her husband has been saying increasingly nonsensical statements at home. In addition, he is no longer able to perform basic verbal tasks such as ordering from a menu or giving directions even though he was an English teacher prior to retirement. She also reports that he has recently started attempting to kiss strangers and urinate in public. Finally, she has also noticed that he has been frequently binge eating sweets even though he was previously very conscientious about his health. When asked about these activities, the patient does not have insight into his symptoms. Which of the following would most likely be seen in this patient?

This patient with disinhibition, early aphasia, hyperorality, and compulsiveness most likely has frontotemporal dementia, which would present with hyperphosphorylated tau inclusion bodies.

A 30-year-old woman underwent bariatric surgery for morbid obesity. The postoperative course was complicated by a bronchopneumonia, vomiting, and poor oral intake. Four weeks after surgery she complained of vertigo and headache and soon became apathetic and developed vertical nystagmus that was worse on downward gaze.

Wernicke Encephalopathy

A 68-year-old man is brought to the physician by his wife because she is concerned about his speech being irregular. Specifically, she says that over the last 8 months, her husband has been saying increasingly nonsensical statements at home. In addition, he is no longer able to perform basic verbal tasks such as ordering from a menu or giving directions even though he was an English teacher prior to retirement. She also reports that he has recently started attempting to kiss strangers and urinate in public. Finally, she has also noticed that he has been frequently binge eating sweets even though he was previously very conscientious about his health. When asked about these activities, the patient does not have insight into his symptoms. Which of the following would most likely be seen in this patient? Review Topic

This patient with disinhibition, early aphasia, hyperorality, and compulsiveness most likely has frontotemporal dementia, which would present with hyperphosphorylated tau inclusion bodies.

A 57-year-old man presents to his primary care physician with a 2-month history of right upper and lower extremity weakness. He noticed the weakness when he started falling far more frequently while running errands. Since then, he has had increasing difficulty with walking and lifting objects. His past medical history is significant only for well-controlled hypertension, but he says that some members of his family have had musculoskeletal problems. His right upper extremity shows forearm atrophy and depressed reflexes while his right lower extremity is hypertonic with a positive Babinski sign. Which of the following is most likely associated with the cause of this patient's symptoms?

This patient with muscle weakness (on physical exam has mixed upper and lower motor neuron signs) most likely has amyotrophic lateral sclerosis, which is associated with mutations in the superoxide dismutase type 1 (SOD-1) gene.

A 75-year-old man is brought to the emergency room after being found unconscious in his home. His medical history is unknown. On physical examination he does not demonstrate any spontaneous movement of his extremities and is unable to respond to voice or painful stimuli. You notice that he is able blink and move his eyes in the vertical plane. Based on these physical exam findings, you expect that magnetic resonance angiogram will most likely reveal an occlusion in which of the following vessels?

This patient with quadriplegia and preservation of vertical gaze most likely has locked-in syndrome due to an occlusion of the basilar artery.

A 71-year-old man presents to his primary care physician because he is increasingly troubled by a tremor in his hands. He says that the tremor is worse when he is resting and gets better when he reaches for objects. His wife reports that he has been slowing in his movements and also has difficulty starting to walk. His steps have been short and unsteady even when he is able to initiate movement. Physical exam reveals rigidity in his muscles when tested for active range of motion. Histology in this patient would most likely reveal which of the following findings?

This patient with resting tremor, bradycardia, rigidity, and instability most likely has Parkinson disease, which could be seen on histology as round eosinophilic inclusions of alpha-synuclein.

A 34-year-old woman comes to the clinic complaining of numbness and tingling of her right arm for 2 days. She reports that she was washing dishes when she felt a burning sensation along her right forearm. The patient has been relatively healthy except for an episode of right eye pain and vision loss 4 years ago. She does not recall specific details but claims that "it just went away on its own after a couple of days." The patient denies any recent travel, trauma, loss of consciousness, speech changes, weakness, or vision change but does endorse gastroenteritis about 1 week ago. She is sexually active with multiple partners and rarely uses contraception. Her last HIV testing 2 weeks ago was negative. A magnetic resonance image (MRI) of her brain is shown in Figure A. What is the most likely explanation for this patient's symptoms?

This patient's neurologic symptoms that are disseminated in space and time (right arm paresthesia and optic neuritis) are characteristic of multiple sclerosis, which results from autoimmune inflammation and demyelination of oligodendrocytes by T-cells.

A 44-year-old man presents to his primary care physician due to a tremor. His tremor has been progressively worsening over the course of several weeks and he feels embarrassed and anxious about going to social events. He says these movements are involuntary and denies having an urge to have these movements. Medical history is significant for depression which is being treated with escitalopram. His mother is currently alive and healthy but his father committed suicide and had a history of depression. Physical examination is remarkable for impaired saccade initiation and brief, abrupt, and non-stereotyped movements involved the right arm. He also has irregular finger tapping. Which of the following is the best treatment for this patient's symptoms?

This patient's non-stereotyped and sudden movements of his right arm, impaired saccade initiation, and psychiatric symptoms (e.g., depression), are highly suggestive of Huntington disease. Deutetrabenazine is a pharmacologic treatment for his motor symptoms (chorea).

A 70-year-old woman with no significant medical history begins to experience memory loss and personality changes. Over the next few months, her symptoms become more severe, as she experiences rapid mental deterioration. She also starts to have sudden, jerking movements in response to being startled and gait disturbances. Eventually, she lapses into a coma and dies eight months after the onset of symptoms. What process likely caused this woman's illness?

This woman most likely suffered from Creutzfeldt-Jakob Disease (CJD), which results from the conversion of an a-helix in a normal protein, termed prion protein (PrPc), to a ß-pleated form. The new ß-pleated protein (PrPSc) resists degradation and facilitates conversion of normal proteins to the abnormal form.

A 28-year-old woman with a history of migraines presents to your office due to sudden loss of vision in her left eye and difficulty speaking. Two weeks ago she experienced muscle aches, fever, and cough. Her muscle aches are improving but she continues to have a cough. She also feels as though she has been more tired than usual. She had a similar episode of vision loss 2 years ago and had an MRI at that time. She has a family history of migraines and takes propranolol daily. On swinging light test there is decreased constriction of the left pupil relative to the right pupil. You repeat the MRI and note enhancing lesions in the left optic nerve. Which of the following is used to prevent progression of this condition?

This young female presenting with sudden loss of vision, difficulty speaking, and a history of a similar episode 2 years ago is most concerning for multiple sclerosis (MS). Natalizumab prevents progression of symptoms and is used in long-term management.

(Thrombotic /Embolic) strokes are caused by a blood clot that develops in the blood vessels inside the brain. Often preceded by transient ischemic attacks (TIAs).

Thrombotic

____________ stroke is a type of ischemic stroke that involves clot formation directly at the site of infarction, typically over an atherosclerotic plaque.

Thrombotic

A 67-year-old man with a prior history of hypertension, diabetes, hyperlipidemia, and a 50 pack-year smoking history noted rapid onset of right-sided weakness and subjective feeling of decreased sensation on his right side. His family reported that he seemed to have difficulty forming sentences. Symptoms were maximal within a minute and began to spontaneously abate 5 minutes later. On arrival in the ER 30 minutes after onset, his clinical deficits had largely resolved with the exception of a subtle weakness of his right hand. Forty minutes after presentation, all of his symptoms were completely resolved.

Transient Ischemic Stroke

Rapid, brief, involuntary, unprovoked motor or verbal response Tic Tremor Chorea Dystonia Myoclonus

Tic

a 73-year-old male with a history of hyperlipidemia, tobacco use, and diabetes arrives at the ER with slurred speech. He was eating dinner with his daughter earlier that night when the symptoms began. She notes that he had a similar episode one year ago that resolved within an hour, as well as an episode of right arm weakness two months ago that resolved within 2 hours. His current symptoms resolve in the ED. His vital signs are as follows: T 99.6 F, BP: 146/96, HR: 76 and O2: 98% on room air. Physical exam reveals bilateral carotid bruits. What is the most likely diagnosis? A. Ischemic Stroke B. Hemorrhagic Stroke C. Transichemic Ischemic Attack D. Subarachnoid Hemorrhage E. Locked-In Syndrome

Transichemic Ischemic Attack

70 year old man followed his wife to her doctor's appointment. While he was there, his wife realized that her husband's left side of the face was drooping and he was slurring his words.They immediately went to the hospital. He was under observation for 24hrs and during that time his symptoms resolved. When he got a carotid ultrasound they found that he had a 80- 99% stenosis in his ICA. He received a carotid endarterectomy a couple of days later. What was his diagnosis? a. Chronic Subdural Hematoma b. Transient Ischemic Attack c. Cerebral Aneurysm d. Arteriovenous Malformation

Transient Ischemic Attack

Rhythmic oscillatory movement of a body part Tic Tremor Chorea Dystonia Myoclonus

Tremor

A middle-aged woman presents with a complaint of frequent (once or twice daily for 3 weeks), brief (lasting several seconds) episodes of intense, sharp left-sided jaw pain. She has experienced these attacks for several years, but they had previously been relatively rare (1 episode daily for several consecutive days followed by months with no attacks). She says that episodes are sometimes brought on by eating but can occur without an apparent stimulus. The patient states that even though the pain is brief, she lives in fear of repeat flares.

Trigeminal Neuralgia

A 70-year-old man presents to the emergency department with confusion after having a convulsive episode. Prior to having a seizure, the patient reported to having a progressively worsening headache that awoke him from sleep, and right-sided weakness over the course of 7 months. On physical exam, there is weakness 2/5 strength throughout the right-side, and a left pupil that is unresponsive to light. A computerized tomography (CT) scan of the head shows a ring-enhancing lesion with surrounding cerebral edema.

Uncal herniation

A 74 year old male is coming into the primary care office after his family saw the patient become "unresponsive" on the toilet. Family members said the patient was unconscious for a few seconds and then regained consciousness. Patient was pale and diaphoretic. What is the most likely cause of this LOC? A) Seizures B) CVA C) TIA D) Vasovagal Syncope

Vasovagal Syncope

P/w vertigo, visual disturbances, facial numbness, or paresthesias, dysphagia, dysarthria, syncope, or hemisensory extremity symptoms

Vertebrobasilar Insufficiency

A 63-year-old man presents with a 3-month history of dizziness. His dizziness comes and goes, but usually lasts for about 10 to 15 seconds. He notices that his dizziness is worse when he rolls over in bed or when he gets out of bed. At one time, he became very dizzy while trying to reach for an object on a high shelf. He does not have any nausea or vomiting associated with it. When it occurs, it is severe, and he has tried to avoid sleeping on his left side. He does not have any hearing loss or tinnitus. He denies aural pressure and headache. His past medical history is otherwise unremarkable. He is not on any medications. On physical examination, he is a healthy appearing 63-year-old man. His temperature is 37.1°C (98.8°F); pulse, 64 beats/min; and blood pressure, 124/74 mmHg. There are no lesions or masses on his face or head. His voice is normal, and his speech is fluent. His facial nerve function is normal. His ear canals and tympanic membranes are normal appearing. His remaining head and neck examination is normal. The cranial nerve examination is normal. The remaining physical examination is normal.

Vertigo, Benign Paroxysmal Position

A 19-year-old man presents with a 2-day history of headache and associated nausea. He says that bright light hurts his eyes. He has no significant past medical history, is not currently taking any medication, and reports no drug allergies. He works as a librarian and has not traveled overseas for the past year. He lives with his girlfriend whom he has been seeing for 2 years. They have a pet hamster.

Viral Meningitis

A 28-year-old man presents to the emergency center with a 48-hour complaint of headache and nausea. The headache is primarily in the frontal and occipital regions and associated with mild nausea. He has taken various over-the-counter analgesics without any improvement in the headache. The intensity of the headache has gradually increased since it began prompting evaluation as he was no longer able to tolerate it. His only other symptom besides nausea is tightness in the shoulders and neck. He is not known to have any medical illnesses, and there is no history of head trauma. On examination, he has a temperature of 32.8°C (100.8°F); blood pressure, 110/68 mmHg; and pulse, of 100 beats/min. He is awake and alert and fully oriented. His Mini-Mental Status Examination (MMSE) is normal; however, he feels he is taking too much time to answer the questions. His general examination is notable for the finding of a Kernig sign without evidence of any skin rash. A Brudzinski sign is not present. Cranial nerves are normal except for bilateral horizontal nystagmus. His motor, sensory, and cerebellar examinations are normal. The deep tendon reflexes are hyperreflexic throughout without evidence of a Babinski sign. A CT scan of the head is performed without contrast, which is read as normal. Importantly his headache is worse now than what it was when he presented to the emergency room.

Viral Meningitis

_______________ is seen on lumbar puncture of a patient with a subarachnoid hemorrhage.

Xanthochromia

You see a patient with new-onset neurologic deficits in the ED. What neurological exam findings would you expect if the patient's MRI angiography is as shown in Figure A? (left-sided lesion labeled with arrow)

You see a patient with new-onset neurologic deficits in the ED. What neurological exam findings would you expect if the patient's MRI angiography is as shown in Figure A? (left-sided lesion labeled with arrow)

Patients with essential tremor often self-medicate with ________________, as it decreases tremor amplitude.

alcohol

A patient presents with weakness that worsens more and more throughout the day, but he is not experiencing any sensory deficits. The patient's Neurology PA suspects Myasthenia. Which of the following could help confirm the diagnosis? a. the presence of acetylcholine receptor autoantibodies b. an EMG that shows decremental muscle response from repetitive stimulation at rates of 3Hz c. a CT of the chest that reveals a thymoma d. all of the above

all of the above

The mechanism of action of _____________ in Parkinson disease treatment is to trigger the release of dopamine from intact nerve terminals and decrease its reuptake.

amantadine

TIA is most closely associated with which of the following? A. amaurosis fugax B. subarachnoid hemorrhage C. lacunar hemorrhage D. intracranial aneurysm E. fusiform aneurysm

amaurosis fugax A TIA usually represents thrombotic particles causing an intermittent blockage of circulation or spasm. Amaurosis fugax, which is described by patients as "a curtain coming down in front of my eyes—a blackout," may be a TIA of the ophthalmic artery. This is associated primarily with the carotid circulation and may also be manifested with contralateral weakness of the face, arm, and legs or numbness. In the situation of a patient with a noncardioembolic stroke or TIA, the use of aspirin (81 mg to 325 mg ), low-dose subcutaneous heparin, or both as well as statins is indicated. A complete workup, including CT scanning to exclude a hemorrhage, MRI, magnetic resonance angiography, and carotid Doppler imaging, is warranted to search for treatable causes of TIA. TIA is a medical emergency, and this group of individuals represent those at highest risk for development of an acute stroke. Those with a TIA have approximately three times the risk for development of an ischemic stroke than those who already have had a stroke, with 50% of the risk coming in the first 48 hours.

Dopamine (agonists/antagonists) and neuroleptics are two classes of drugs that can cause drug-induced Parkinson-like syndrome.

antagonists

Stroke involving the _________ cerebral artery affects the motor and sensory cortices of the contralateral lower limbs, resulting in paralysis and sensory loss.

anterior

The most common site of saccular aneurysm rupture causing subarachnoid hemorrhage is at the junction of the __________ _____________ artery and anterior cerebral artery.

anterior communicating

Huntington disease is an example of _____________, a genetic term described as increased severity or earlier onset of disease in succeeding generations.

anticipation

Silent strokes typically (are/are not) detected with neuroimaging techniques.

are

Ischemic stroke risk can be reduced with medical therapy including _________ and clopidogrel.

aspirin

The treatment for a TIA is enteric-coated __________ in the acute phase followed by long-term antiplatelet therapy for noncardioembolic TIA and anticoagulation for cardioembolic etiology.

aspirin

The wife of a 48-year-old male patient brings him to the emergency room and says that his memory has progressively gotten worse over the last several years. She also says his personality has been changing. The physician notes abnormal writhing movements of the man's limbs and hyperreactive reflexes. MRI reveals a loss of volume in the neostriatum and cortex. In which of the following ways is this disease transmitted? A. Autosomal dominant trait B. Autosomal recessive trait C. Chromosomal nondisjunction D. X-linked dominant trait E. X-linked recessive trait

autosomal dominant Huntington disease is a neurodegenerative autosomal dominant disorder characterized by symptoms of decreased muscular, mental, and behavioral declines. It is caused by increased CAG repeats in the Huntingtin gene.

Stroke involving the paramedian pontine reticular formation forces the eyes to look (toward/away from) the lesion.

away from

Huntington disease is a movement disorder characterized by the degeneration of gamma-aminobutyric acid-ergic neurons in the caudate nucleus of the ______________.

basal ganglia

A Ruptured _______________ _______________ accounts for approximately 75% of nontraumatic cases of subarachnoid hemorrhage and has a mortality rate of 50%.

berry aneurysm

Primary medical therapy for essential tremor include (drug class) __________ and anti-convulsants.

beta blockers

Ischemic stroke involves acute ________ of vessels and resulting ischemia.

blockage

Huntington disease is a movement disorder characterized by the degeneration of gamma-aminobutyric acid-ergic neurons in the _________ nucleus of the basal ganglia.

caudate

45-year-old woman presents to the ED with acute painless loss of vision, photophobia associated with a smaller unilateral pupil on the involved side. Which of the following is the most likely diagnosis? A. central retinal vein occlusion (CRVO) B. iritis/uveitis C. retrobulbar hemorrhage or hematoma D. hyphema E. central retinal artery occlusion

central retinal artery occlusion Central retinal artery occlusion is characterized by acute visual loss usually attributed to ischemic or thrombus to the major retinal arterial blood supply.

Saccular aneurysmal ruptures that cause subarachnoid hemorrhage occur most frequently in the anterior half of the _____ _____ ______.

circle of Willis

A 67-year-old male is seen by neurology after he was noticed to be speaking strangely by his family. After acute treatment with tissue plasminogen activator (tPA), the patient is able to recover most of his speech. Subsequent neurologic exam finds that the patient is fluent while speaking and is able to comprehend both one and two step instructions. Noticeably the patient remains unable to complete tasks involving verbal repetition.

conduction aphasia, which is caused by isolated damage to the arcuate fasciculus.

Dopamine levels in Parkinson disease (increase/decrease).

decrease

Serotonin levels in Parkinson disease (increase/decrease) .

decrease

Acetylcholine levels in the central nervous system are (increased/decreased) in Huntington disease.

decreased

Gamma-aminobutyric acid levels are (increased/decreased) in Huntington disease.

decreased

In Parkinson disease, positron emission tomography shows (increased/decreased) uptake of fludeoxyglucose in the basal ganglia.

decreased

Huntington disease is an autosomal (dominant/recessive) movement disorder involving CAG trinucleotide repeats in the Huntingtin gene on chromosome 4.

dominant

Parkinson's disease is associated with a central nervous system neurotransmitter deficiency. What is that neurotransmitter? A. acetylcholine B. serotonin C. γ-aminobutyric acid D. dopamine E. norepinephrine

dopamine

In trinucleotide repeat diseases, such as Huntington disease, the more trinucleotide repeats, the _________ the age of onset.

earlier

Essential tremors are high frequency tremors with sustained posture, which are (exacerbated/alleviated) ________________ with movement of the affected muscles.

exacerbated

Stroke involving the ________ lobe results in disinhibition, deficits in concentration, orientation, and judgment.

frontal

There are many sources of potential emboli that may cause a CVA. The most common source of cerebral emboli is which of the following? A. carotid arteries B. aortic arch C. heart D. vertebral¬basilar arteries E. middle cerebral artery

heart

Acetylcholine levels in Parkinson disease (decrease/increase).

increase

Dopamine levels are (increased/decreased) in Huntington disease.

increased

The cerebral blood vessels most commonly affected by thrombotic stroke are the branching points of the ____________ ___________ artery, and the middle cerebral artery.

internal carotid

A 59-year-old presents with right-sided hemiparesis, right-sided sensory loss, leftward eye deviation, and slurred speech. A head CT is performed which is significant for a hyperdense lesion affecting the putamen. The patient has a history of hypertension treated with hydrochlorothiazide, but is non-adherent. Which of the following is most likely associated with the cause of this patient's neurological deficits?

intraparenchymal hemorrhage (IPH)

A family history (is/isn't) commonly present in essential tremor, a neurological disorder typically causing action or postural tremor in the arms and hands.

is

Replacement of dopamine with __________ in Parkinson disease alleviates the symptoms but does not cure the disease.

levodopa

A 41-year-old woman presents to the emergency department complaining of a sudden onset of the "worst headache of my life." A stat computed tomography (CT) scan of her head is found to be normal. The next appropriate step in the diagnosis of this patient would be: A. outpatient magnetic resonance imaging (MRI) of the brain B. complete blood cell count (CBC) with differential C. injection of sumatriptan (Imitrex) D. lumbar puncture E. repeat CT scan in 48 hours

lumbar puncture The hallmark of a subarachnoid hemorrhage is the very sudden onset of a severe headache. The headache is often described as the "worst headache of my life." A CT scan will detect a subarachnoid hemorrhage in more than 95% of cases. When the history suggests subarachnoid hemorrhage and the CT scan fails to detect bleeding, a lumbar puncture is mandatory. The lumbar puncture will yield bloody cerebrospinal fluid in subarachnoid hemorrhage. Outpatient MRI or repeat CT scan in 48 hours would create a potentially harmful delay in diagnosis. CBC with differential may be ordered but will not confirm the suspected diagnosis. Treatment with Imitrex is contraindicated in the presence of a potential cerebrovascular syndrome.

Stroke involving the caudal (medulla/pons) affects the hypoglossal nerve, resulting in ipsilateral tongue deviation.

medulla

Strokes involving the lateral pons or _____________ may result in dysmetria, ataxia, and ipsilateral Horner syndrome due to involvement of cerebellar peduncles and sympathetic fibers.

medulla

Stroke involving a portion of the reticular activating system located in the ____________ may result in reduced levels of arousal and wakefulness, possibly resulting in a coma.

midbrain

Stroke involving the ___________ cerebral artery involves the motor and sensory cortices controlling the contralateral upper limb and face.

middle

The (anterior/middle) cerebral artery is most commonly affected by embolic ischemic strokes.

middle

The _____________ system is the major dopaminergic pathway in the brain and it has decreased activity in Parkinson disease.

nigrostriatal

Before tissue plasminogen activator can be administered for a stroke, (contrast/non-contrast) head CT should be performed to rule out hemorrhage.

non-contrast

A subarachnoid hemorrhage is a type of cerebral hemorrhage that presents with headache and ___________ ___________

nuchal rigidity.

Thrombotic ischemic stroke causes a (red/pale) infarct.

pale

Huntington disease is a movement disorder characterized by involuntary writhing of muscle groups. It consists of a clinical triad that includes the following: progressive dementia, chorea, and a pattern of inheritance progressive dementia, tremor, and a pattern of inheritance depression, tremor, and a pattern of inheritance depression, chorea, and a pattern of inheritance

progressive dementia, chorea, and a pattern of inheritance

Selegiline and ____________ are two monoamine oxidase-B inhibitors that can be used alone as initial treatment of Parkinson disease; or, as an adjunct alongside levodopa.

rasagiline

Tetrabenazine and _____________ are medications used to treat chorea in Huntington disease by inhibiting vesicular monoamine transporter, a monoamine transporter protein which guides dopamine to the synapse.

reserpine

Parkinson disease is characterized by the presence of (resting/kinetic) tremors.

resting

What is (are) the drug(s) of choice for mild cases of the Parkinson's disease (mild meaning that the main or only symptom is tremor)? A. amantadine B. trihexyphenidyl C. levodopa-carbidopa D. ropinirole or pramipexole E. selegiline or rasagiline

selegiline or rasagiline

Lewy bodies found in Parkinson disease are present in the _________ ____________ regions of the brain.

substantia nigra

Where is the lesion associated with Parkinson's disease located? A. caudate nucleus B. substantia nigra C. hypothalamus D. globus pallidus E. putamen

substantia nigra

The main difference between a migraine and subarachnoid hemorrhage is that subarachnoid hemorrhage has a (sudden/slow) onset.

sudden

Ischemic stroke risk can be reduced by optimizing control of blood pressure, blood _________ , and lipids.

sugar

Tufts of ____ protein in astrocytes, or tufted astrocytes, are considered diagnostic for progressive supranuclear palsy.

tau

Treatment for ischemic stroke includes __________ ___________ ____________ if given within 3-4.5 hours of symptom onset and no risk of hemorrhage.

tissue plasminogen activator

Stroke involving the frontal eye fields forces the eyes to look (toward/away from) the lesion.

toward

A 42¬year¬old white man presents to your office with a complaint of decreased vision that, with further questioning, he describes as "a curtain coming down over my eyes." The patient's past medical history included hypertension and hyperlipidemia, and he recently admitted to extensive use of cocaine. He denies intravenous drug use, vertigo, diplopia, ataxia, or an abnormal heart rate. If you had the choice of one test to help determine the etiology of his symptoms, what would that be? A. ultrasonography of the carotid arteries B. CT scan of the brain C. MRI scan of the brain D. lumbar puncture

ultrasonography of the carotid arteries This patient has had a TIA. Amaurosis fugax and his cocaine use may have contributed to this TIA. Cocaine probably caused an intense vasospasm; it is an intensely powerful vasoconstrictor, much more powerful than either angiotensin II or thromboxane. This patient needs an ultrasound examination of his carotid arteries, and he needs it soon. Treatment will be based on etiology, and a workup and consultation should be conducted quickly.

A 77 year old woman presents to the emergency department with the following signs and symptoms: dysarthria and dysphagia, vertigo, nausea, syncope, memory loss and disorientation, and ataxic gait. On physical examination, the patient has nystagmus, homonymous hemianopia, numbness in the area of the 12th cranial nerve, and facial weakness. You suspect a CVA. Which of the following arteries is most likely to be involved? A. middle cerebral artery B. posterior cerebral artery C. vertebral-basilar artery D. anterior cerebral artery E. posterior inferior cerebellar artery

vertebral-basilar artery This patient has had a CVA involving the vertebral-basilar system. The signs and symptoms of vertebral-basilar stroke are (1) dysarthria and dysphagia; (2) vertigo, nausea, and vomiting; (3) disorientation; (4) ataxic gait (ipsilateral cerebellar ataxia); (5) visual symptoms (double vision and blurred vision); (6) dysphagia; (7) ocular signs (nystagmus, conjugate gaze paralysis, and ophthalmoplegia); (8) akinetic mutism (locked¬in syndrome when basilar artery occlusion occurs); (9) numbness of lips and face; (10) facial weakness, alternating motor paresis; and (11) drop attacks, syncope (Doppler studies can detect vertebrobasilar embolic sources).

36-y/o woman with family h/o renal cell carcinoma presents with gait disturbance and blurred vision; PE: retinal hemangiomas, nystagmus, cerebellar ataxia, dysdiadokinesia; MRI shows two cerebellar cystic lesions.

von Hippel-Lindau Disease