Neurology Module 1

An elderly male patient with dementia presents with his daughter who reports sudden deterioration in his level of function over and above his usual level of confusion.

On examination he has difficulty copying a clock face. He draws a full circle and then fills all the numbers on one side of the clock face.

He is also noted to have difficulty putting on his coat.

What is the most likely cause for his deterioration?

A 65 year old man was brought in to the emergency department after his wife heard some grunting noises in bed. She noticed that he had a left facial droop and a dense hemiplegia. The attending physician diagnosed the man as having an acute stroke. An urgent MRI was performed soon after arrival.

An acute ischemic lesion in the right parietal area was detected with diffuse weighted MRI (DWI) but not with fluid-attenuated inversion recovery (FLAIR) imaging.

What is the significance of this finding?

Which of the following drug could potentially lead to lamotrigine toxicity?

Levetiracetam is becoming more frequently used as add-on therapy for epilepsy.

What is the major concern about its use?

A 40 year old patient presents with intense vertigo, tinnitus and sense of fullness in the right ear.

Examination during an attack shows fine rotary nystagmus that is maximal on gaze to the left .Otherwise, neuro exam is unremarkable.

An audiogram shows high-tone hearing loss in the right ear, with recruitment but no tone decay.

What is the most likely diagnosis?

A 64 year old man with a background of hypertension and Type 2 diabetes presents with 3 days history of ongoing vertigo associated with spontaneous nystagmus.

Which of the following clinical finding would be concerning for a central cause for his vertigo?

Deep brain stimulation is a recently recognized form of treatment modality for patients with Parkinson’s disease.

Which of the following symptom is most likely to respond to this treatment?

Which of the following clinical feature would suggest a stroke mimic rather than a true stroke?

A 56 year old man who is otherwise fit and well develops sudden onset of right sided arm and leg weakness along with a right facial droop at 9am on a Saturday morning. His NIHHS score is 12. His bloods are all unremarkable.

An urgent CT head shows an acute left middle cerebral territory infarct. The time is now 12pm.

What would be the best treatment for this patient to reduce his disability and mortality?

A 56 year old man who is otherwise fit and well develops sudden onset of right sided arm and leg weakness along with a right facial droop at 9am on a Saturday morning. His NIHHS score is 12. His bloods are all unremarkable.

An urgent CT head shows an acute left middle cerebral territory infarct. The time is now 2pm. A CT angiogram showed a visible clot in the left middle cerebral artery.

What would be the best treatment for this patient to achieve functional independence following his stroke?

A 57 year old lady presents to ED within an hour’s onset of an acute ischemic stroke. An occlusion in the right middle cerebral artery is demonstrated on her head CT. Unfortunately, the hospital has run out of supply of intravenous alteplase.

Which of the following thrombolytic agent is likely to provide her with the best possible outcome prior to performing endovascular thrombectomy?

A 35 year old alcoholic man presents with unsteadiness whilst walking. On examination he has diminished deep tendon reflexes. Proprioception and vibration sense are absent in both legs. He also has cerebellar tremor in the hands.

Which of the following conditions is most likely to be responsible for his weakness?

The following motor tracts are predominantly responsible for axial and proximal limb movements except?

A 40 year old lady from Christchurch with no significant past medical history presents with 3 days history of numbness in her lower extremities. She reports being well until 3 days ago when she noted tingling and numbness in her feet bilaterally. Over the next 72 hours these sensations ascended to involve her calves and thighs and now are up to her waistline. Since the morning, she has noted that she is dragging her right leg and has difficulty emptying her bladder. She denies any headache, vision changes or changes in her upper extremities.

On neurologic examination, she had a GCS of 15 and was oriented to time and place. Her cranial nerve examination is normal. The upper limbs had normal tone and 5/5 strength throughout with no drift. However, the lower limbs were notable for 4/5 strength at the right iliopsoas, 4/5 at the right quadriceps and hamstrings and 3/5 strength at the right ankle dorsiflexion. The left lower extremity had 5/5 strength throughout except for the iliopsoas which was 4+/5. She had normal proprioception and vibration throughout but had decreased temperature and pinprick in her legs bilaterally, with a T10 sensory level noted. Deep tendon reflexes were 2+ at the biceps, triceps and brachioradialis. They were absent at the patellas and ankles.Finger to nose is intact, but the patient was unable to perform a complete heel to shin. On gait testing, there was circumduction of the right leg and a right foot drop.

MRI of the brain and spine is obtained.Brain MRI is normal but the thoracic MRI showed increased signal at the T9 region. The results of her full blood count and comprehensive metabolic panel are all normal. However, CSF shows pleocytosis with raised oligoclonal bands and IgG index.

Based on the above findings, all of the following treatment would be helpful except?

A 30 year old man has a painful right eye. On examination, there is decreased visual acuity and a relative afferent pupillary defect of the right eye. What is the diagnosis?

The McDonald diagnostic criteria was recently revised in 2017 and it incorporated clinical and MRI findings for the diagnosis of multiple sclerosis. The core requirement of the diagnosis is the objective demonstration of dissemination of lesions in both space (DIS) and time (DIT).

For DIS, the MRI must demonstrate 1 or more T2 lesion in at least 2 of 4 areas of the CNS. These areas would include the following except?

The following clinical features are all suggestive of multiple sclerosis except?

Which of the following condition is most likely to respond to glucocorticosteroids?

A 50 year old lady with a known history of multiple sclerosis (MS) has been on treatment with Natalizumab for the last 6 months and now presents with symptoms that are concerning for progressive multifocal leukoencephalopathy (PML).

Which of the following would suggest the diagnosis of PML rather than her MS?

Ocrelizumab is a novel humanized monoclonal antibody that selectively depletes CD20-expressing B cells. Which of the following condition would it be most useful for?

A 55 year-old woman reports dizziness for the past 2 weeks. Several times a day, she experiences a severe sensation of spinning that is triggered by head movements, such as when he turns over in bed or looks upward. The sensation — which lasts about 15 seconds, is associated with transient nausea, and resolves spontaneously — is not accompanied by hearing changes, tinnitus, headache, fever, congestion, or other neurologic symptoms.

You maneuver the patient rapidly from a seated to a supine position while his supported head is turned to the side and then extended below the level of the table. Two seconds after the maneuver is started with the patient’s head turned to the right, the patient experiences severe vertigo with mixed torsional and vertical nystagmus.

Which one of the following treatments is most likely to be effective for this patient’s condition?

If a patient with Myasthenia gravis undergoes a repetitive nerve stimulation test, what changes could be expected in the post-synaptic miniature end-plate potentials?

Which of the following disabilities seen in Parkinson’s disease is not related to Levodopa?

Which of the following feature is least consistent with the diagnosis of essential tremor?

A neurologist is assessing a 65 year old man for the cause of bilateral hand tremors which are worsening. Which of the following makes ‘Parkinson’s disease tremor’ more likely than a ‘benign essential tremor’?

A 67-year-old man, with a history of smoking 20 cigarettes per day, presents with acute onset of painless loss of vision in the right eye, as if a curtain has suddenly descended over the right eye. After five minutes, vision returned quite rapidly. There are no associated neurological symptoms. Cranial magnetic resonance imaging (MRI) is normal.

His carotid angiogram shows 70 percent stenosis of the right internal carotid artery.

Which one of the following interventions will give the greatest reduction in his risk of stroke or death in the next year?

In patients who presents with an acute idiopathic facial neuropathy (Bell’s Palsy), which of the following patient group is least likely to benefit from early initiation of prednisolone?

Which of the following anti-epileptic drug would reduce the serum levels and effects of lamotrigine?

A person develops a right parietal infarct.
In addition to hemiparesis, which of the following clinical signs would you expect to be associated with this abnormality?

The posterior reversible encephalopathy syndrome (PRES) is associated with the following conditions EXCEPT?

In the setting of an acute stroke, which vessel would have the best chance of recanalisation following thrombolysis with intravenous alteplase?

A 65 year old man has a pacemaker in-situ for complete heart block. His other medical background includes hypertension and diet controlled diabetes. He recently completed a routine pacemaker check and this recorded a low burden of atrial fibrillation lasting less than 10 minutes over the 6 months period. He is currently asymptomatic.

Which of the following medication is likely to reduce his risk of developing a stroke in the future?

A 56-year-old man with a history of hypertension managed with enalapril presented to ED following an ischemic cerebrovascular stroke. Intravenous alteplase was administered, and within an hour, the patient developed severe swelling on the right side of his tongue requiring emergent intubation. Subsequent imaging revealed an acute-to-subacute infarct in the left occipital lobe of the posterior cerebral artery.

Which of the following intervention should be avoided in this situation?