Demo Neurology Module 4

A 66-year-old woman presents to the emergency department with sudden onset of left-sided weakness and difficulty speaking.

She has a history of hypertension and hyperlipidaemia.

A non-contrast CT of the head reveals a large right middle cerebral artery (MCA) infarct with significant oedema and midline shift. Her Glasgow Coma Scale (GCS) is 8, and her blood pressure is 180/100 mmHg (normal <140/90 mmHg).

What is the most appropriate next step in managing this patient?

Perform an urgent decompressive craniectomy to relieve raised intracranial pressure

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Administer thrombolytic therapy to dissolve the clot

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Initiate aggressive blood pressure management to reduce the risk of further stroke

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Transfer the patient to a rehabilitation center for physical therapy

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Perform a cerebral angiogram to evaluate for vasculitis

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Which of the following factors is most likely to precede an episode of transient global amnesia?

Plunge in cold water

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Consumption of a balanced meal

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Light physical activity such as walking

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Listening to soothing music

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Reading a book in a quiet room

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A 70-year-old woman with newly diagnosed atrial fibrillation presents with sudden onset of dizziness, difficulty walking and slurred speech.

Examination reveals ataxia and dysmetria.

CT confirms a left cerebellar infarct, and MRI shortly afterwards reveals haemorrhagic infarction (petechial, HI2).

Regarding initiation of oral anticoagulation, which of the following statements is most appropriate?

Timing should be individualised; early initiation (within 4–14 days) is reasonable for minor–moderate infarcts, guided by haemorrhage severity

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Anticoagulation should never be commenced

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Anticoagulation should be commenced immediately

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Warfarin is preferred over a DOAC in this setting

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Anticoagulation must be delayed for a minimum of 30 days regardless of infarct size

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A 45-year-old man presented to the Accident & Emergency department following sudden onset left posterior auricular pain while in his garage working under his car.

On examination, he had a degree of neck pain and stiffness and also impaired coordination of left hand and weakness and increased tone in his right limbs.

What is the most likely diagnosis?

Vertebral artery dissection

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Cervical spondylosis

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Tension headache

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Migraine

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Subarachnoid haemorrhage

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A 54 year-old male presents with progressive pins and needles and numbness in both feet which have deteriorated over the last six months.

He has a 10 year history of Type 2 diabetes mellitus and had cervical spondylosis for which he underwent surgery 8 years ago. He also confessed to drinking approximately 40 units of alcohol weekly.

On examination he had a mild bilateral weakness of foot dorsiflexion, both ankle reflexes were absent and plantar responses were flexor. There was absent sensation to light touch to mid-shin level with loss of joint position sensation in the toes and absent vibration sensation below the hips.

He had a marked sensory ataxia and pseudoathetosis of upper limbs. He had no evidence of a retinopathy and urinalysis was normal.

What is the most likely diagnosis?

Chronic Inflammatory Demyelinating Polyneuropathy

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Guillain-Barré syndrome

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Alcohol induced neuropathy

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Spinal cord infarction

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Diabetic peripheral neuropathy

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A patient has, on examination, weakness in plantar flexion and foot inversion on the left. He also is unable to tiptoe on the same foot. Ankle jerk is absent.

Which of the following nerve lesion is most likely?

Tibial nerve

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Common peroneal nerve

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L4 nerve root

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Sciatic nerve

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Femoral nerve

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A 65 year old man presents with muscle weakness and difficulty swallowing. On examination, he has proximal and distal upper and lower limb weakness. There is wasting of the intrinsic muscles of the fingers and of his thigh muscles. CK is elevated and EMG findings are consistent with a myopathic process. Which condition is likely?

Inclusion body myositis

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Polymyositis

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Dermatomyositis

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Motor neuron disease

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Duchenne muscular dystrophy

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A 55-year-old man with type 2 diabetes presents with acute headache and ptosis of the right eye.

The right eye is deviated “down and out,” and he has impaired adduction, elevation and depression.

The pupil is normal in size and reactive. There is no fatigability.

CT angiography of the head is normal, excluding a posterior communicating artery aneurysm.

Which of the following is the most likely diagnosis?

Cavernous sinus thrombosis

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Pupil-sparing (microvascular) third nerve palsy.

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Myasthenia gravis

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Pituitary tumour

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Horner's syndrome

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A 30-year-old gym instructor complains of progressive shoulder pain and weakness over 5 years, with difficulty lifting weights he previously managed easily.

Examination reveals scapular winging, reduced power around the shoulders with bilateral wasting, and difficulty raising the eyebrows.

Serum CK is 400 U/L (normal 45–250 U/L).

What is the likely diagnosis?

Facioscapulohumeral dystrophy

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Duchenne's muscular dystrophy

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Becker's muscular dystrophy

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Myotonic dystrophy

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Polymyalgia rheumatica

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A 65-year-old man has proximal muscle weakness. Needle EMG shows short-duration, low-amplitude, polyphasic motor unit potentials with early recruitment.

Which of the following conditions is most likely?

Polymyositis

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Myasthenia gravis

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Amyotrophic lateral sclerosis

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Guillain-Barré syndrome

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Charcot-Marie-Tooth disease

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A 60 year old right handed patient presents with disorientation. Examination reveals left right disorientation, acalculia, agraphia and finger agnosia.

Where is the lesion?

Left angular gyrus

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Right cingulate gyrus

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Right angular gyrus

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Left fusiform gyrus

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Left cingulate gyrus

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A 60 year old woman has had difficulty walking due to unsteadiness. She has lost 5 kg in weight over the past 6 months. On examination, she has horizontal nystagmus. Her speech is slurred. There is incoordination of the upper limbs evident on past pointing. Her gait is ataxic. General examination reveals a palpable breast lump. Which of the following is likely to yield a diagnosis?

Anti-Yo antibodies

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Anti-Hu antibodies

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Anti-GAD antibodies

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MRI of the brain

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CT of the head

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Which patient is at the highest risk for developing delirium?

A 68-year-old woman admitted to the intensive care unit (ICU) with esophageal rupture

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A 36-year-old man admitted to the medical ward with a deep venous thrombosis

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A 55-year-old man postoperative day 2 from a total colectomy

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A 74-year-old woman in the preoperative clinic before hip surgery

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An 84-year-old man living in an assisted living facility

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Which of the feature is least consistent with the diagnosis of myasthenia gravis?

Presence of sensory deficit

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Increasing weakness with repeated exertion

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Fluctuation of symptoms over the course of a day

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Response to pyridostigmine

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Diplopia

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According to the TOAST classification, which single mechanism is most frequently identified as the cause of ischaemic stroke and TIA in Western populations?

Large-artery atherosclerosis (atheroembolism)

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Aneurysm

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Cardioembolic

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AV malformation

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Amyloidosis

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What is the strongest modifiable risk factor for stroke or TIA?

Older age

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Atrial fibrillation

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Hypertension

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Hyperlipidemia

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Cigarette smoking

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A 62-year-old man presents with sudden onset of right sided weakness lasting for 10 minutes then resolved spontaneously. On examination, GCS 14. His neurological exam is unremarkable. BP is 150/60.

Other medical problems include hypothyroidism and diabetes. ECG shows normal sinus rhythm

What should be the next step in management?

Admit to hospital for observation.

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Reassurance and discharge from ED

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Urgent CT Head

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Thrombolysis with Alteplase

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Commence on warfarin

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A 32 year old woman presented 4 days postpartum with two seizure episodes. Her mentation waxed and waned until after several hours, staff were unable to arouse her with voice or touch.

Her CT scan shows vasogenic edema predominantly in the occipito-parietal area bilaterally.

The patient’s condition declined to a coma. She remained comatose despite therapeutic interventions to control increased intracranial pressure.

What is the most likely diagnosis?

Posterior Reversible Encephalopathy Syndrome (PRES)

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Reversible Cerebral Vasoconstriction Syndrome (RCVS)

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Stroke Like Migraine Attacks after Radiotherapy (SMART)

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Bilateral watershed infarct

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Multiple sclerosis

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A 25-year-old woman has had several episodes of brief jerking of the right arm over the past few weeks without loss of consciousness.

Neurological examination and CT of the head are unremarkable, and she is diagnosed with focal epilepsy.

Which is the most appropriate first-line medication to commence?

Carbamazepine

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Diazepam

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Levetiracetam

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Lamotrigine

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Levodopa

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A 32 year old female presents with a recent history of severe headache which is worse in the morning and improves through the day. She also complains of blurred vision in the left eye with diplopia on leftward gaze.

Her BMI is >30. On examination, she is normotensive with BP of 110/60 with bilateral papilloedema on fundoscopy.

A brain MRI and MRV shows no intracranial pathology and no evidence of thrombosis.

Which of the following is the most appropriate investigation to help establish the diagnosis?

Lumbar puncture

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Visual evoked potential

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Cerebral angiography

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Blood culture

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Syphilis serology

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Which of the following feature is not consistent with the diagnosis of pseudotumor cerebri (Idiopathic intracranial hypertension)?

Reduced level of consciousness

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Symptoms of raised intracranial pressure

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No localizing signs with the exception of abducens (sixth) nerve palsy

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Normal MRI findings

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LP opening pressure of >25 cmH2O

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A 63-year-old man of Han Chinese background presents to the emergency department 6 hours after a transient episode of right-hand clumsiness and word-finding difficulty lasting 25 minutes.

On arrival his symptoms have fully resolved, his National Institutes of Health Stroke Scale (NIHSS) score is 0, and his ABCD² score is 5.

His medical history includes hypertension and dyslipidaemia.

Non-contrast CT of the head shows no haemorrhage, and CT angiography demonstrates no large-vessel occlusion or significant carotid stenosis.

He is diagnosed with a high-risk transient ischaemic attack.

Pharmacogenomic testing reveals that he carries two CYP2C19 loss-of-function alleles (*2/*3), identifying him as a poor metaboliser.

Which of the following antiplatelet strategies is most likely to reduce his risk of recurrent stroke over the next 30 days?

Aspirin and ticagrelor

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Aspirin alone

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Clopidogrel alone

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Aspirin and clopidogrel

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Clopidogrel and warfarin

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A 55-year-old woman with poorly controlled type 2 diabetes (HbA1c 130 mmol/mol, approximately 14%) presents with three weeks of intermittent headaches and swirling flashes of light affecting her right visual field.

She has moderate non-proliferative diabetic retinopathy.

Examination reveals a right inferior quadrantanopia with an otherwise unremarkable neurological examination.

Admission blood glucose is 21.7 mmol/L (normal fasting 3.0–5.4 mmol/L) with negative urinary ketones. CT of the head is normal.

MRI shows atypical signal changes in the left medial primary visual cortex (subcortical T2 hypointensity with overlying cortical changes).

Which intervention is most likely to be helpful?

Improve glycaemic control.

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Intravenous immunoglobulin

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Plasma exchange

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High dose IV methylprednisone

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Anti-convulsant therapy

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In the setting of an acute stroke, which of the following CT perfusion parameters would likely result in the best outcome from reperfusion therapy?

Reference:

MTT = Mean Transit Time

CBF = Cerebral Blood Flow

CBV= Cerebral Blood Volume

Increased MTT, moderately reduced CBF and increased CBV

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Increased MTT, markedly reduced CBF and markedly decreased CBV

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Decreased MTT, increased CBF and increased CBV.

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Decreased MTT, decreased CBF and decreased CBV.

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Increased MTT, markedly reduced CBF and near-normal CBV

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A 68-year-old man presents to the emergency department 3 hours after sudden onset of right-sided hemiparesis, global aphasia, and gaze deviation. His National Institutes of Health Stroke Scale (NIHSS) score is 18. Blood pressure is 165/90 mmHg. A non-contrast CT brain shows no haemorrhage with an Alberta Stroke Program Early CT Score (ASPECTS) of 8. CT angiography is performed to identify a target for mechanical thrombectomy.

Which of the following vessel occlusions has the strongest, most established evidence base for endovascular thrombectomy?

Proximal M1 segment of the middle cerebral artery

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Distal M3 segment of the middle cerebral artery

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Posterior cerebral artery P2 segment

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Anterior cerebral artery A2 segment

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Isolated distal cervical internal carotid artery

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Demo Neurology Module 4

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