Mock 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?

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

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?

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?

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?

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?

A 35 year old woman has been admitted to hospital for investigation of progressive weakness in her legs for the past 5 years. Her mother has similar weakness and sensory problems.

Examination reveals power of 3/5 distally in the upper and lower limbs with a glove-and-stocking pattern of sensory loss to pain and touch.

What is the diagnosis?

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?

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?

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?

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

Where is the lesion?

A 35-year-old man is admitted with acute right-sided weakness and slurred speech. He has no vascular risk factors and no family history of stroke, and is a non-smoker. He reports intermittent headaches and generalised limb weakness.

Examination reveals hypotonia and proximal-predominant weakness.

Serum lactate is elevated with a high lactate-to-pyruvate ratio.

Which is the most likely diagnosis?

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?

Which patient is at the highest risk for developing delirium?

Which of the following intervention is least beneficial in the management of raised intracranial pressure following a large intracranial bleed?

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

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

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

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?

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?

A 46 year old female presents with recurrent episodes of “explosive thunderclap” bilateral headache for the last 5 days. Her headache may occur spontaneously or on exertion. She has a past history of migraine and amphetamine use.

Lumbar aspirate was negative for xanthochromia.

Initial CT head was normal but a repeat CT Head done 5 days later showed bilateral watershed infarct.

What is the most likely diagnosis?

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?

A 28-year-old woman with juvenile myoclonic epilepsy is taking sodium valproate 1200 mg/day. She is now pregnant.

Assuming she continued this medication throughout pregnancy, all of the following fetal or neonatal adverse effects are recognised associations, EXCEPT?

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?

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

A 67 year old female presents with loss of voluntary eye movement although reflex eye movement is preserved.

She is unable to identify certain objects when it is shown in front of her and is unable to grasp the object when instructed to do so.

Where is the lesion?

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?

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?

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

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?