Neurology Board Review

Question 1

A 72 year old man presents with acute onset vertigo, nystagmus, dysphagia, and horners syndrome. The most likely diagnosis is?

Your Choices….

1. Acute Labryinthitis

2. Benign paroxysmal positional vertigo

3. Lateral Medullary Infarction

4. Opthalmoplegic Migraine

Lateral Medullary Infarction!AKA Wallenberg SyndromeIpsilateral face Pain and Temperature Dysphagia Dysarthria Nystagmus +/- limb ataxiaContralateral Limbs Pain and Temperature-Lateral Spinothalamic tract

Posterior Circulation Strokes The 5 D’s of Brainstem Dysphagia Dysarthria Diplopia Dystaxia Dizziness Syncope/ Drop attack Ipsilateral Face, Contralateral Extremity

Visual Field Deficits

Vertigo

Peripheral

-Sudden

-Tinnitus, Auditory

-Severe n/v/dizzy

-Horizontal Nystagmus

-May be positional, recent infections

Central

-Insidious

-No peripheral sx

-Less severe n/v/dizzy

-Vertical or Horizontal Nystagmus

-Not positional, may have peripheral neuro deficits

Question 2

A 74 year old female with history of DM, HTN, presents with 2 hours onset right face, arm > leg weakness with an associated right hemisensory deficit. No left sided deficits. No cranial nerve deficits. What is the most likely diagnosis?

1. Basilar Artery Occlusion2. Subarachnoid Hemorrhage3. Lacunar Infarction4. Middle Cerebral Artery Occlusion5. Posterior Cerebral Artery Occlusion

Middle Cerebral Artery Occlusion Lateral parietal,

temporal, and frontal lobes

Contralateral Motor/ and Sensory Face and Arm > leg

Ipsilateral Hemianopsia Aphasia/ Dysarthria

(left sided stroke) Agnosia / Neglect,

extinction of double stimulus (right parietal lobe)- timing!

CT Finding with MCA OcclusionHyperdense MCA sign

Loss of cortical ribbon

Sulcal EffacementObscuration of the grey/white junction

The Wrong Answers!

1.Basilar Artery Occlusion: Locked In

2.Subarachnoid Hemorrhage: HA

3.Lacunar Infarction: Pure motor or sensory

4.Posterior Cerebral Artery Occlusion: Primary visual disturbances

Question 3

A 43 year old female presents to the ER with her husband. Her husband states that his wife has been having the worst headache of her life and is “a bit off”. On exam she uncomfortable and confused without focal motor or sensory deficits. A CT scan is obtained.

Question 3

What is the most common etiology for the diagnosis revealed by the CT scan?

1. AVM

2. Cavernous Angioma

3. Mycotic Aneurism

4. Neoplasm

5. Saccular Aneurysm

Saccular Aneurysm

80% of non-traumatic SAH are associated with saccular aneurysm

5% of the population have aneurysms; increase risk of rupture includes-

a. Smokingb. EtOHc. Stimulant Abused. Uncontrolled HTN

Subarachnoid Hemorrhage

Collection of blood in subarachnoid space Secondary to trauma, ruptured aneurysm, AVM 2-4% Patient visits for HA 2-4% will have SAH; 12 % of pts with worst

headache of life will have SAH, increases to 25% if abnormal neurologic exam

Headache 100%, Nausea and emesis 77%, focal deficits 64%, syncope 53%, neck pain 33%, photophobia, seizures in 25% of patients

20-50% have prior warning headache “sentinel bleed” days to weeks prior

Cranial Nerve 6 (abducens) palsy; lateral rectus; ACOM

Cranial Nerve 3 (occulomotor) palsy; ptosis, medial, superior, inferior gaze, pupillary constrictors; PCOM

Subhyaloid Hemorrhage

Question 4

An 84 year old man with h/o HTN, DM, AFIB on coumadin presents with left sided hemiparesis and left sided hemisensory changes with left sided neglect. He has a GCS of 15. Thirty minutes into his assessment his GCS falls to 11 with profound confusion. What is the most likely cause?

1. Anterior Cerebral Artery Embolism

2. Internal Capsule Intracerebral Hemorrhage

3. Posterior Cerebral Artery Rupture

4. Posterior Cerebral Artery Thrombosis

5. Vertebral Artery Occlusion

Internal Capsule Intracerebral Hemorrhage

Hemorrhagic transformation may occur during an apparent ischemic stroke

Sudden change in conciousness= ICH V.S posterior circulation CVA

Reversal of anticoagulation

Intracranial Hemorrhage

8-13% of all strokes 30 day mortality 44%, brainstem ICH 75% 24 hour Only 20% of pts regain full functional independence Increase incidence: AA, Asian, age >55, EtoH, Smokers Trauma, HTN, altered homeostasis, hemorrhagic

necrosis, venous outflow obstruction Causes brain injury via:1. Increased Intracranial Pressure2. Increase edema, mass effect3. Decrease perfusion to local and adjacent tissue4. 35% ICH will expand sig (>33%) within 24 hours; majority within 6 hours

ICH

Basal Ganglia 40-50% Lobar: 20-50% (esp young, increased sz activity)

Thalamus 10-15% Pons 5-12% Cerebellar 5-10% Brain Stem 1-5% Intraventricular Hemorrhage 1/3 BG

Volume= (a+b+c)/2

ICHGCS 3-4 2

5-12 1

___________13-15 0

ICH Vol >30 1

___________<30 0

IVH Yes 1

___________No 0

Infratentoral Yes 1

___________No 0

Age >80 1

___________<80 0

0-6

Question 5

A 45 year old male presents with nausea, emesis, and diarrhea. He is given 2 liters of IVF and 12.5mg of promethazine. 15 minutes later he is anxious and wants to leave the ED immediately. What is the diagnosis and management?

1. Anxiety or who cares. Let him go AMA2. Is he tolerating PO? Give him some reglan and get him out.3. I think he is delirious. Give him some haldol and call

psych.4. I think he is having a reaction to the med. Lets give him

Prochlorperazine. Right?

5. I think he is having a reaction to the med. Lets give him

some Benztropine.

Akathisia- benztropine

Acute distonic reaction marked by anxiety, restlessness

Other distonic rexns include torticollisAssociated with high potency antipsychotic (haldol), and any dopaminergic medications (promethazine, metoclopramide, prochlorperazine)

Treatment includes anti-cholinergic medications such as diphenhydramine and benztropine (not to use in kids less than 3)

Question 6

A 65 year old male with DM, HTN, BPH, recent diagnosis of sciatica p/w 2 days of progressive difficult ambulation with worsening back pain radiating down to left leg. Exam is noteable for hyporeflexia with downgoing toes, +4/5 lower extremity strength, saddle paresthesia, and deminished rectal tone.

1. Stroke

2. Sciatica

3. Cauda Equina Syndrome

4. Acute back pain

5. Spinal Abcess

Cauda Equina Syndrome

Ca, Infiltrative, Sarcoidosis, Trauma, Infectious, Ank Spon

Pain, radicular Weakness- variable Hyporeflexia v.s spinal

Saddle sensory changes

Overflow incontinance urine/stool

Cauda Equina Syndrome

MRI or CT Myelography Neurosurgical consultation

Steroids + RT- randomized controled high dose, non-radnomized low dose; end treatment and 6 months in ability to ambulate

Radical ressection + RT

Other options

Sciatica Radicular Pain Lateral or post leg to foot

Straight leg raise (10-60), crossed

Numbness, no weakness

NSAIDS

Epidural Abcess Staph (MRSA) 63%; Gram Neg,

Strep, Anaerobes, TB (potts) Multiple levels Epidurals, Surgical, IVDU,

Cryptogenic DM, ETOH, HIV Pain, Fever, Weakness MRI/ CT w/ gadolinium Surgical Decompression

/Aspitation Abx: Nafcillin (Vanc)

+Flagyl+

Ceftazidime or Cefotaxime

Should I get the imaging….? Progressive neurological findings

Constitutional symptoms (fever)

History of traumatic onset

History of malignancy

Age 18 years or 50 years

IVDUChronic steroidsHIVOsteoporosisPain > 6 weeks

*American college of radiology “Red Flags”

Question 7

Which of the following pretreatment patient characteristics has been associated with an increased risk of intracerebral hemorrhage following treatment with TPA for acute ischemic stroke?

1. Advanced Age2. Increased NIHSS3. Isolated global

aphasia4. Major surgery

within 14 days5. Rapid improvement

of neurological signs

Increased Stroke Severity

Increase stroke severity via NIHSS and increasing radiographic signs of infarct size on CT are two independent predictors of ICH after TPA

Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. NEJM. 1995 333:1581-1587.

Double-blind, randomized, placebo controlled

Pts tx with rTPA are 30% more likely to have minimal to no disability at 3 months compared to standard care

Increase risk of symptomatic ICH (6.4%) with increasing NIHSS

American Heart Association, American Academy of Neurology, ACEP (if system in place)

tPAInclusion Criteria

Age > 18

Diagnosis of stroke with measurable deficit

Time of onset < 3 hours before treatment will begin

Relative Contraindications

Major surgery or serious trauma within 2 weeks

Only minor or rapidly improving stroke sx

History of GI or GU hemorrhage within 21 days

Recent arterial puncture as non-compressable site

Glucose >400, <50

Post MI pericarditis

Patient with observed seizure at time of stroke onset

Recent Lumbar Puncture

Exclusion Criteria

Evidence of ICH on CT

History of ICH or AVM

Suspected SAH with normal CT

Active internal bleeding

Platelets < 100,000

Heparin within 48 hours with an elevated PTT

Current use of oral anticoagulant with PT> 15sec

SBP > 185 or DBP >110 at time treatment is to begin

Within 3 months any intracranial surgery, serious head injury, or previous stroke (not TIA)

Question 8

A 32 year old man who lives in New England presents complaining of bilateral leg weakness. His symptoms began with paresthesias in his toes followed by progressive weakness in both legs. Cranial nerve exam is normal. Motor s 3/5 in both legs, 4/5 both arms and sensation to light touch is mildly decreased in both legs. DTR’s are absent in both legs and +1 in b/l arms. What is the most likely diagnosis?

1. Lambart-Eaton Syndrome2. Familiar periodic paralysis3. Guillan Barre Syndrome4. Myasthenia gravis5. Tick paralysis

Guillain-Barre Syndrome

Immune-mediated; motor, sensory, and autonomic dysfunction

GBS the most common cause of acute flaccid paralysis in the United States

Pure motor and motor + sensory subtypes. 40-80% seropositive for Campylobacter jejuni Haemophilus influenzae, Mycoplasma pneumoniae,

and Borrelia burgdorferi. CMV, EBV, HIV 85% of pts with normal recovery 6-18 months

Guillain-Barre Syndrome

Ascending weakness from proximal thighs to trunk and upper extremities

Cranial nerves, respiratory muscles (1/3rd)

Paraesthesias distal to proximal, Proprioception, sensory

Autonomic dysfunction; HR, BP, Temp, Fecal and urinary retention

Guillain-Barre Syndrome

Clinical diagnosis supported by: Elevated or rising protein levels on serial

lumbar punctures (90% pts) 1-2 weeks CSF pleocytosis in HIV associated Cauda Equina nerve roots enhance in 85% ABG and FVC to assess respiratory function,

intubate for ventilatory failure IVIG and plasma exchange tx

OthersMyasthenia gravis-Autoantibodies against post-synaptic Ach receptors -Bulbar sx initialy- ptosis, diplopia, dysphagia, 1% resp-Descending weakness-Thymoma 10-15%-Sx improve with restLambart-Eaton Syndrome-Autoantibodies against voltage gated calcium channels in

pre-synaptic motor nerve terminal-Proximal lower extremity weakness (up from chair), months-Less common bulbar findings-Highly associated with cancer (50-70%)-Sx improve with movement

Others

Familial periodic paralysis-AD, variable penetrance-Chanelopathy resulting in inexcitability of Na/Ca

channels leading to periodic flacid paralysis-Hyperkalemic and Hypokalemic subtypes-Worsened by heat, stress, high carbohydrate mealsTick paralysis-Caused by neurotoxin from salivary gland-Ascending paralysis 1-2 weeks-Ataxia variant-Rock Mountain wood tick (Dermacentor andersoni) and

American dog tick (Dermacentor variabilis)

Question 9 A 25 year old male presents with 1 day of severe right sided head and neck pain with blurred blurred vision. He states he went to his chiropracter in the morning before symptom onset. On exam he has right sided miosis and ptosis with normal motor function and sensory function. What is his most likely diagnosis?

1. Right brainstem cva

2. Cluster Headache

3. Bells Palsy

4. Tick Bite

5. Carotid artery dissection

Carotid Artery Dissection

Unilateral facial/neck/orbital pain

Hypoageusia Transient blindness, amaurosis

fugax 50% w/ partial horners syndrome- miosis, ptosis, no anhydrosis

25% pulsitle tinnitus Neck swelling, bruise May progress to CVA with dense hemiparesis

Trauma Chiropractic manipulation

Sports, yoga CTD HTN Smoking Oral contraceptives

Horners Syndrome Sympathetic fibers run upwards vis cervical spine ganglia

Bifruncate at division of CC to IC and EC (sweat glands)

Innervate pupilary dilators (dilation lag) and lids

Migraine, Brainstem CVA, Pancoast tumor, brachial plexus trauma, Lung lesion (TB, HMX), neuronal lesion

Diagnosis and Treatment

Angiography gold standard

MRA optimal if available

CT angiogram evolving, esp for trauma pts

Anticoagulation with heparin

Neurosurgical consultation

Question 10

A 43 year old male presents to the emergency room with 2 hours onset decreased movement of right side of face, ear pain, and thinks he might have had spoiled milk with his cereal this am because it tasted funny. What is the least important question for the diagnosis?

1. When was the milks expiration date?

2. Can he move his forehead?

3. Does he have a history of migraine?

4. Does he have clustered vesicles about the ear?

5. Does he have peripheral motor weakness?

Bells Palsy- Not spoiled milk. Facial Nerve CN 7 palsy Upper and lower facial weakness

Post auricular pain Hyperacusis (stapedius) Hypoageusia (ant 2/3 tongue)

Decreased lacrimation 30% pts w/ Crocodile tears, dysagusia, partial paralysis; 80-90% without sig deficit

Bells Palsy

CausesHSV 1,2

VZV

Mycoplasma pneumoniae

Borrelia burgdorferie

HIV (b/l)

Adenovirus

coxsackievirus

Ebstein-Barr virus

Hepatitis A, B, and C

Cytomegalovirus

TreatmentPrednisone 60mg/day X 7 days

Acyclovir 800mg 5X/day for 7 days

Valacylovir 1000mg TID for 7 days

Artificial Tears

Bells Palsy- Treating Ourselves? Prednisone treatment for idiopathic facial paralysis (Bell's palsy). N

Engl J Med 1972 Dec 21; 287(25): 1268-72; 89% pred, 64% placebo Cochrane Database 2002- Corticosteroids for Bell's palsy (idiopathic

facial paralysis). No sufficient support for steroids Cochrane Database 2004- randomized(?) trials of acylovir or valtrex

with or without steroids for treatment of bells palsy ; insufficient evidence for support of antiviral medications

Valacyclovir and prednisolone treatment for Bell's palsy: a multicenter, randomized, placebo-controlled study; Otol Neurotol. 2007 Apr;28(3):408-13. N=221; 6-8% improvement in severity and complete remission

Ramsey-Hunt Syndrome

Herpes Zoster Oticus; HSV1, HSV2, VZV

Triad of auricular pustules, ear pain, ipsilateral facial paralysis

+/- Hypoaguseia and hyperacusisWorse prognosis

Question 11

38 y/o female with a history of epilepsy presents with multiple seizures without return to consciousness for 30 minutes. Her finger stick is 100 and her blood ICON is negative. The patient has been given 4 mg of ativan X2 but continues to seize. What is your next step?

1. 4 mg Midazolam 2. 8 mg Ativan 3. Vitamin B64. Fosphenytoin load5. Succinylcholine and etomidate with ETT

Fosphenytoin Load

Status Epilepticus30 minutes of seizure activity without return of consciousness

If seizure >4-5 minutes consider status; neuronal injury- must wake up!

Non-convulsive- EEG!Treatment of status based on universal guidelines and institutional protocol

Treatment and investigation parallel

Status Epilepcitcus

1/3rd new onset 1/3rd epilepsy 1/3rd: Idiopathic Hyper/hyponattremia Hypercalcemia Hypoglycemia CVA Trauma Infectious Mass HE

Toxins INH Tricyclics (AVR, QRS) Theophylline Cocaine Sympathomimetics Alcohol withdrawal Organophosphates

(strychnine) DM medications (glucose)

Status Epilepticus

1st Line: Ativan 4 mg over 2 minutes q5 min X2If no access 20mg diazepam pr, 10mg midazolam IM

2nd Line: IV Fosphenytoin (20mg/kg at 150mg/min; may add 10mg/kg)

May give IV Keppra, Valproic Acid, Phenobarbitol if pt is on it

3rd Line: Pentobarbitol, Intubation with continuous drip of midazolam or propofol

Other: Vitamin B6 (70mg/kg up to 5 )

Question 12

A 35 year old female 1 week post-partum presents with 1 day of severe headache, nausea and vomiting. She is slightly confused and lethargic. She is afebrile, normo-tensive, with a negative UA. Given the clinical picture, what is the treatment of choice?

1. PCC or FFP2. Emergent Craniotomy3. Serial lumbar punctures4. Magnesium Sulfate IV5. Heparin

Heparin, Venous Sinus Thrombosis Headache, nausea, emesis, ams, focal deficits; pesudotumor cerebri

Women, peripartum, hypercoaguable states, systemic inflammatory conditions

CT head, MRV Atypical ischemic or hemorrhagic region

Tx: Heparin

Question 13

A 70 year old male presents to the ER with weakness in the leg upon waking this morning. His exam shows left leg 2/5 strength with ataxia of limb, 4/5 left arm strength, no facial droop. He keeps asking what time it is. Where is his lesion?

1. Middle Cerebral Artery

2. Anterior Cerebral Artery

3. Posterior Cerebral Artery

4. Basilar Artery

5. Carotid Artery

Anterior Cerebral Artery Stroke Affects medial parietal, temporal, and frontal lobes

Contralateral Motor and Sensory Leg > face and arm

Dis-inhibition, perseveration, primitive reflexes

Basilar Artery Stroke

Bilateral sxComaLocked in syndrome

Question 14

A 23 year old patient presents is BIBEMS being bagged with a GCS of 3. His friend is with him and states that while doing “a lot” of cocaine his friend developed severe headache with sudden loss of conciousness. Which of the following considerations in further management is incorrect?

1. Pretreat with lidocaine and consider fentanyl and vecuronium

2. Do not allow single episode of hypoxia or hypotension

3. Hyperventilate to pC02 25-30

4. Raise head of bed to 30 degrees

5. Consider manitol or hypertonic saline for deterioration in neurologic status

Maintain pCO2 between 35-40, not any lower!Pretreatment Oxygen NRB Lidocaine 1.5mg/kg 3 minutes before

Fentayl 2ug/kg Vecuronium .01mg/kg (De-fasciculating Dose)

Intubation by most experienced MD; single episode of hypoxia associated with poor outcome

Ventilation

*Short term hyper-ventilation for nerologic deterioration

*Maintain pCO2 35-40

*Long term hyper-ventilation not Rx

Management of elevated ICP CPP=MAP-ICP Maintain cerebral perfusion

Do not lower BP by > 20%

General rule is to maintain systolic between 160-180

A single hypotensive episode is assoicated with worse outcomes

Tx hypotension with IVF

Treatment of Increased ICP includes:

-Mannitol

-Raise Head of bed 30 D

-Hypertonic Saline (future)

-Hyperventilation

-Surgical evacuation

Question 15

A 45 year old inmate with no pmhx presents with 1 hour of headache, right leg and arm paralysis, left forearm numbness, third right toe numbness, and a voice in his head telling him that he is hungry. Which of the following must you concsider in your differential?

1. Hypoglycemia

2. Metabolic Derangement

3. Migraine

4. CVA

5. All of the above

All of the Above!

Hypoglycemia (may be focal) Seizure, Todds paralysis

(may last 24 hours) CNS infection Bells Palsy (forehead

affected) Other Metabolic derangement Migraine (focal deficits

possible) Conversion disorder Malingering Lower CNS lesion, trauma Toxic

THE END

THANK YOU!Please also read-Parkinsons-Dimentia-Delerium-Multiple Sclerosis-Everything else!

Question 16 ? If you want more… A 22 year old female presents with double vision.

The symptoms disappear with either eye is covered. Extraoccular movements are intact when tested individually. On conjugate gaze testing there is nystagmus in the left eye and limited adduction in the right eye. What is the most likely cause?

1. Dislocated Lense2. Tertiary neurosyphilis3. Internuclear Opthalmoplegia4. Sixth Nerve palsy5. Third Nerve palsy

Internuclear Opthalmoplegia Occurs due to disruption in the medial longitudinal fasciculus (MLF)

Corrdinates conjugate eye movements Most commonly due to MS MS occurs in young women; deficits vary anatomically and temporally

Diplopia

MonocularRefractive error

Dislocated lenses

IridodialysisMalingering

Binocular CN palsies Brain lesions HTN crisis Cocaine Wernicke’s SLE Retro-orbital

mass/hematoma