Neurology Module 4

A 66-year-old woman presents to the emergency department with a sudden onset of left-sided weakness and difficulty speaking. She has a history of hypertension and hyperlipidemia. A non-contrast CT scan of the head reveals a large right middle cerebral artery (MCA) infarct with significant edema and midline shift. Her Glasgow Coma Scale (GCS) is 8, and she has a blood pressure of 180/100 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 to the emergency department with sudden onset of dizziness, difficulty walking, and slurred speech.

Neurological examination reveals ataxia and dysmetria.

A CT scan of the brain confirms a left cerebellar infarct. An MRI conducted shortly after reveals signs of early hemorrhagic transformation.

When should anti-coagulation be considered?

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. The patient’s mother has similar difficulties with weakness and sensory problems.

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

What is the diagnosis?

A 40 year old bank clerk presents with a headache and ptosis of the right eye. She does not have fatiguability of her eye movements. The pupil sizes are equal. She has a full range of eye movements. A CT venogram is normal.

Which of the following is the most likely diagnosis?

A 30 year old gym instructor complained of shoulder pain and weakness which has been progressive over the past 5 years. He is upset about having difficulty lifting weights which he had previously been able to do so without difficulty. On examination, there was winging of the scapula. Power was reduced in the muscles around the shoulder, with bilateral wasting. He also has some facial difficulty raising his eyebrows. His serum CK is 400. What is the likely diagnosis?

A 65 year old man has muscle weakness. EMG shows reduced amplitude and duration of motor units. Which of the following conditions is 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 does not have a history of hypertension, diabetes or high cholesterol. There is no family history of CVA. He does not smoke. He complains of headaches and generalised limb weakness infrequently. On examination, he has hypotonia and weakness in the proximal muscles more than the distal muscles. His laboratory tests show a high lactate to pyruvate ratio. Which is the 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?

What is the most common cause of ischaemic stroke or TIA?

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 secretary has had several episodes of brief jerking of the right arm over the past few weeks. There is no loss of consciousness. A CT scan of the head is unremarkable. Which is the best medication to commence?

A 28 year old woman is diagnosed with juvenile myoclonic epilepsy and is on treatment with Sodium Valproate at a dose of 1200mg/day.

Should she decide to continue this medication during her pregnancy, then the following adverse effects could potentially occur to the fetus, except?

Which of the following is NOT a side effect of Pegylated Interferon beta used in the management of multiple sclerosis?

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 patient presents with right sided hemiplegia and left sided facial weakness and is unable to abduct his left eye.

Where is the lesion?

An individual denies being blind.

Where is the lesion?

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 patient presents with left droopy eyelid and difficulty adducting his left eye and has right sided weakness of both his upper and lower limb.

On examination, the left eye is deviated down and out (infraducted, abducted) and there is ptosis on the left eye

Where is the lesion?

Among patients with a TIA or minor stroke (NIHSS score of <5) who can be treated within 24 hours after the onset of symptoms, which therapy is likely to reduce the risk of stroke within the next 30 days?

A 55-year-old lady with a background of very poorly controlled Type 2 diabetes (HBA1c of 145) presents with three weeks history of intermittent headaches associated with swirling flashes of lights mainly affecting her right visual field. She is known to have moderate non-proliferative diabetic retinopathy with macula micro-aneurysms and has previously had bilateral cataract surgery without diabetic macular oedema.

Clinically, she has a right inferior quadrantanopia, but the rest of her neurological examination were mostly unremarkable. Her blood glucose on admission was 21.7 with negative urinary ketones.

Her CT head on admission was normal, however, her brain MRI subsequently showed ‘atypical changes’ in her left medial primary visual cortex as depicted below:

Which of the following intervention will most likely be helpful in this condition?

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