Neurology Module 2

A 65-year-old man presents acutely to ED with symptoms consistent of a transient ischemic attack (TIA) with a low NIHSS score. His symptoms resolved within an hour of his presentation.

Imaging reveals minor ischemic changes with no large infarcts. The patient’s past medical history includes atrial fibrillation, for which they are unable to tolerate oral anticoagulants.

Which of the following is the most appropriate management for this patient?

A 25-year-old woman presents to the clinic following a second episode of visual loss in her right eye accompanied by eye pain that worsens with movement. The first episode occured last month while she was at her office which resolved spontaneously after several hours.

Her medical history is unremarkable, and she has no known autoimmune disorders. Upon examination, an MRI shows inflammation of the optic nerve.

Her cerebrospinal fluid shows normal glucose and protein and no oligoclonal bands. MOG-antibody positive, but Aquaporin-4 negative.

Her serum ACE is negative and so is her auto-immune screen (ANA/ENA).

Which of the following conditions is most likely associated with her clinical presentation?

Which of the following medications is least appropriate as the initial treatment for severe migraine?

A 15-year-old previously well male presents to the emergency department with sudden onset of flaccid paraplegia and urinary retention. He reports that symptoms started immediately after performing a backflip during gymnastics practice. He describes a brief, sharp mid-thoracic back pain at the onset. He denies any trauma to the head or spine. Neurological examination reveals:

• 0/5 power in both lower limbs
• Loss of pain and temperature sensation below T8
• Preserved proprioception and vibration sense
• Normal upper limb neurological function
• No spinal tenderness

MRI spine shows T2 hyperintensity and cord swelling at the T6–T9 levels, involving predominantly the anterior cord, without any mass lesion or disc herniation.

CSF analysis is normal, with no pleocytosis and mildly elevated protein.

His full blood count, electrolytes and CRP are all within normal limits.

Which of the following is the most likely diagnosis?

A 65-year-old woman with a history of hypertension, hyperlipidemia, and type 2 diabetes presents to the emergency department with symptoms of acute ischemic stroke, including left-sided weakness and slurred speech. Her blood pressure is 180/100 mmHg, and her blood glucose level is 250 mg/dL.

Imaging reveals a medium vessel occlusion (MeVO) of the middle cerebral artery beyond the proximal dominant M2 segment. The patient’s NIH Stroke Scale (NIHSS) score is 12, indicating moderate stroke severity. She is currently taking aspirin, metformin, and atorvastatin, and has no known allergies.

Which of the following is the most appropriate treatment recommendation for this patient?

An 84-year-old man comes to your clinic to be evaluated for a 5-year history of a gradually worsening gait and a 2-year history of cognitive impairment and urinary incontinence. Twelve years ago, he sustained a closed head injury that caused a mild traumatic subarachnoid hemorrhage and had lost consciousness for five hours.

His current medications include Zopiclone and multivitamins.

On physical examination, he is afebrile with stable observations. His BMI is 27.

The patient’s gait is slow and unsteady and is marked by small, shuffling steps.

His level of alertness, speech, posture, arm swing, and muscle tone are all normal, and he has no tremor.

He scores 24/30 on the Folstein Mini Mental State Examination, losing one point in the orientation portion for incorrectly stating today’s date, three points in the serial calculation portion, and two points in the recall portion.

Results of a complete blood count, a basic metabolic panel, serum vitamin B12 measurement, thyroid function tests, and a urinalysis are normal.

What is the most likely diagnosis?

A 65 year old man is assessed on the ward for weakness in his legs. He is an ex smoker and drinks 15 units of alcohol in a week. His wife mentions that he is confused.

On examination, his MMSE score is 20/30. He has an ataxic gait. There is bilateral pyramidal weakness and coordination is impaired.

Routine blood tests are normal. An MRI scan of the head shows diffuse white matter changes, more in the cerebellar region than the cerebrum.

Which test would be most helpful in confirming the diagnosis?

A 65 year old man of Māori descent has nystagmus looking to the left, ataxia and vertigo. He also has a left sided Horner’s syndrome. There is loss of pain and temperature on the left side of the face and a loss of pain and temperature on the right side of the trunk and limbs.

Which of the following is the diagnosis?

Which of the following feature is most suggestive of a cluster headache compared to a migraine attack?

Lumbar puncture should be preceded by CT or MRI in all of the following subsets of patients suspected of having meningitis EXCEPT those with:

A 27 year old lady has been referred from the ophthalmology clinic with bilateral papilloedema. She has a background of obesity with BMI of 35 and a previous renal calculi. She had been complaining of having blurred vision for several months associated with a chronic dull left sided headache so decided to see the optometrist as she thought she needed glasses. On visual testing, the left eye had a large blindspot and the optic discs were swollen bilaterally. Other cranial nerve and motor exam was unremarkable.

CT head was normal. A lumbar puncture demonstrated an opening pressure 31cm H2O and a closing pressure 16cm H2O. The CSF glucose, protein and chemistry were normal. MRI and MRV showed some narrowing of the dural venous sinuses but no thrombosis seen. The pituitary is unremarkable in appearance and no other significant abnormality was seen.

Based on the above clinical findings, which of the following treatment/intervention would be least helpful?

Which of the following mutation occurs in the Familial form of Amyotrophic Lateral Sclerosis (FALS)?

Which investigation is most useful in making the diagnosis of motor neuron disease?

A 30 year old man presents with weakness of tongue and mouth muscles.

He also complains of increasing weakness of his limb muscles. He has been trying to have children with his partner but has been unsuccessful.

On examination, there is evidence of muscle wasting, fasciculations and gynecomastia.

What is the most likely diagnosis?

In motor neuron disease, which of the following interventions are most likely to prolong survival?

What is the mechanism of action of Riluzole?

A patient who presents purely of lower motor neuron signs will likely to have?

A patient who presents purely of upper motor neuron signs will likely to have?

All of the following are associated with poor survival in motor neuron disease except?

What is the most common cause of death in MND?

Which of the following drug increases the serum level of carbamazepine?

Which of the following anti-epileptic drug may cause osteoporosis?

Which of the following anti-epileptic drug has the most teratogenic effect in pregnancy?

Which of the following anti-epileptic drugs may cause visual field changes?

Which of the following anti-epileptic drug causes weight loss?

A 22 year old woman with a history of epilepsy decides to use an oral contraceptive pill to prevent pregnancy.

Which Anti-epileptic drug should she use?

Which of the following drugs should be avoided in juvenile myoclonic epilepsy?

Which of the following anti-convulsants is most likely to Increase the half life of lamotrigine?

The following treatments are useful in essential tremor except?

What is the most common symptom of excess levodopa?

What is the mechanism of action of amantadine?

A 68-year-old patient with a history of early-stage Alzheimer’s disease has been enrolled in a clinical trial for a new amyloid-targeting therapy. After 4 months of treatment, the patient presents with sudden onset confusion, headache, and a mild right-sided weakness.

An MRI of the brain reveals bilateral asymmetric white matter hyperintensities suggestive of vasogenic edema, predominantly in the occipital regions, without evidence of cerebral hemorrhage.

The patient’s recent treatment history and imaging findings are most consistent with which of the following diagnoses?

A 75-year-old patient with a history of atrial fibrillation, managed on warfarin, presents to the emergency department with sudden onset of right-sided weakness and aphasia. Imaging confirms an intracerebral hemorrhage (ICH). The patient’s INR is significantly elevated, indicating the need for rapid anticoagulation reversal.

What is the most appropriate next step in managing this patient to improve survival and reduce the likelihood of discharge to hospice, considering the importance of rapid treatment?

A 62-year-old man presents to a tertiary hospital in New Zealand with sudden onset of right-sided hemiplegia and global aphasia. Imaging reveals occlusion of the left middle cerebral artery with a large ischemic core.

Which of the following is the most appropriate next step in management?

A 55-year-old woman with a history of atrial fibrillation presents to the emergency department with acute onset of left-sided weakness and dysarthria. A non-contrast CT scan of the head is performed to evaluate for ischemic stroke.

In the context of using the Alberta Stroke Program Early CT Score (ASPECTS) to assess the extent of ischemic changes, which of the following best describes the ASPECTS methodology?