Neurology Board Review

Question 1

A 72 year old man presents with acute

onset vertigo, nystagmus, dysphagia,
and horners syndrome. The most likely
diagnosis is?
Your Choices….

1. Acute Labryinthitis
2. Benign paroxysmal positional vertigo
3. Lateral Medullary Infarction
4. Opthalmoplegic Migraine
Lateral Medullary Infarction!
AKA Wallenberg
Syndrome
Ipsilateral face
 Pain and Temperature
 Dysphagia
 Dysarthria
 Nystagmus
 +/- limb ataxia
Contralateral Limbs
 Pain and Temperature
-Lateral Spinothalamic
tract
Posterior Circulation Strokes
 The 5 D’s of Brainstem
 Dysphagia
 Dysarthria
 Diplopia
 Dystaxia
 Dizziness
 Syncope/ Drop attack
 Ipsilateral Face,
Contralateral Extremity
 Visual Field Deficits
Vertigo
Peripheral Central
-Sudden -Insidious
-Tinnitus, Auditory -No peripheral sx
-Severe n/v/dizzy -Less severe n/v/dizzy
-Horizontal Nystagmus -Vertical or Horizontal
-May be positional, recent Nystagmus
infections -Not positional, may have
peripheral neuro deficits
Question 2

A 74 year old female with history of DM, HTN,

presents with 2 hours onset right face, arm >
leg weakness with an associated right
hemisensory deficit. No left sided deficits. No
cranial nerve deficits. What is the most likely
diagnosis?
1. Basilar Artery Occlusion
2. Subarachnoid Hemorrhage
3. Lacunar Infarction
4. Middle Cerebral Artery Occlusion
5. Posterior Cerebral Artery Occlusion
Middle Cerebral Artery Occlusion
 Lateral parietal,
temporal, and frontal
lobes
 Contralateral Motor/ and
Sensory Face and Arm
> leg
 Ipsilateral Hemianopsia
 Aphasia/ Dysarthria (left
sided stroke)
 Agnosia / Neglect,
extinction of double
stimulus (right parietal
lobe)- timing!
CT Finding with MCA Occlusion

 Hyperdense MCA
sign
 Loss of cortical
ribbon
 Sulcal Effacement
 Obscuration of the
grey/white junction
The Wrong Answers!

1. Basilar Artery Occlusion: Locked In

2. Subarachnoid Hemorrhage: HA
3. Lacunar Infarction: Pure motor or
sensory
4. Posterior Cerebral Artery Occlusion:
Primary visual disturbances
Question 3
 A 43 year old female
presents to the ER with
her husband. Her
husband states that his
wife has been having
the worst headache of
her life and is “a bit off”.
On exam she
uncomfortable and
confused without focal
motor or sensory
deficits. A CT scan is
obtained.
Question 3

 What is the most 1. AVM

common etiology for 2. Cavernous Angioma
the diagnosis 3. Mycotic Aneurism
revealed by the CT
4. Neoplasm
scan?
5. Saccular Aneurysm
Saccular Aneurysm

 80% of non-traumatic SAH are associated

with saccular aneurysm
 5% of the population have aneurysms;
increase risk of rupture includes-
a. Smoking
b. EtOH
c. Stimulant Abuse
d. Uncontrolled HTN
Subarachnoid Hemorrhage
 Collection of blood in subarachnoid space
 Secondary to trauma, ruptured aneurysm, AVM
 2-4% Patient visits for HA
 2-4% will have SAH; 12 % of pts with worst headache of
life will have SAH, increases to 25% if abnormal
neurologic exam
 Headache 100%, Nausea and emesis 77%, focal deficits
64%, syncope 53%, neck pain 33%, photophobia,
seizures in 25% of patients
 20-50% have prior warning headache “sentinel bleed”
days to weeks prior
 Cranial Nerve 6
(abducens) palsy;
lateral rectus; ACOM
 Cranial Nerve 3
(occulomotor) palsy;
ptosis, medial, superior,
inferior gaze, pupillary
constrictors; PCOM
 Subhyaloid
Hemorrhage
Question 4

 An 84 year old man with h/o HTN, DM, AFIB

on coumadin presents with left sided
hemiparesis and left sided hemisensory
changes with left sided neglect. He has a
GCS of 15. Thirty minutes into his
assessment his GCS falls to 11 with profound
confusion. What is the most likely cause?
1. Anterior Cerebral Artery Embolism
2. Internal Capsule Intracerebral Hemorrhage
3. Posterior Cerebral Artery Rupture
4. Posterior Cerebral Artery Thrombosis
5. Vertebral Artery Occlusion
Internal Capsule Intracerebral
Hemorrhage
Hemorrhagic transformation may occur
during an apparent ischemic stroke
Sudden change in conciousness= ICH
V.S posterior circulation CVA
Reversal of anticoagulation
Intracranial Hemorrhage

 8-13% of all strokes

 30 day mortality 44%, brainstem ICH 75% 24 hour
 Only 20% of pts regain full functional independence
 Increase incidence: AA, Asian, age >55, EtoH, Smokers
 Trauma, HTN, altered homeostasis, hemorrhagic necrosis, venous
outflow obstruction
 Causes brain injury via:
1. Increased Intracranial Pressure
2. Increase edema, mass effect
3. Decrease perfusion to local and adjacent tissue
4. 35% ICH will expand sig (>33%) within 24 hours; majority within 6
hours
ICH
 Basal Ganglia 40-50%
 Lobar: 20-50% (esp
young, increased sz
activity)
 Thalamus 10-15%
 Pons 5-12%
 Cerebellar 5-10%
 Brain Stem 1-5%
 Intraventricular
Hemorrhage 1/3 BG
 Volume= (a+b+c)/2
ICH
GCS 3-4 2
5-12 1
___________13-15 0
ICH Vol >30 1
___________<30 0
IVH Yes 1
___________No 0
Infratentoral Yes 1
___________No 0
Age >80 1
___________<80 0
0-6
Question 5
 A 45 year old male presents with nausea, emesis, and
diarrhea. He is given 2 liters of IVF and 12.5mg of
promethazine. 15 minutes later he is anxious and wants to
leave the ED immediately. What is the diagnosis and
management?
1. Anxiety or who cares. Let him go AMA
2. Is he tolerating PO? Give him some reglan and get him out.
3. I think he is delirious. Give him some haldol and call psych.
4. I think he is having a reaction to the med. Lets give him
Prochlorperazine. Right?
5. I think he is having a reaction to the med. Lets give him
some Benztropine.
Akathisia- benztropine

 Acute distonic reaction marked by anxiety,

restlessness
 Other distonic rexns include torticollis
 Associated with high potency antipsychotic
(haldol), and any dopaminergic medications
(promethazine, metoclopramide,
prochlorperazine)
 Treatment includes anti-cholinergic
medications such as diphenhydramine and
benztropine (not to use in kids less than 3)
Question 6
 A 65 year old male with 1. Stroke
DM, HTN, BPH, recent
diagnosis of sciatica p/w 2. Sciatica
2 days of progressive 3. Cauda Equina
difficult ambulation with
worsening back pain Syndrome
radiating down to left leg. 4. Acute back pain
Exam is noteable for
hyporeflexia with 5. Spinal Abcess
downgoing toes, +4/5
lower extremity strength,
saddle paresthesia, and
deminished rectal tone.
Cauda Equina Syndrome
 Ca, Infiltrative,
Sarcoidosis, Trauma,
Infectious, Ank Spon
 Pain, radicular
 Weakness- variable
 Hyporeflexia v.s spinal
 Saddle sensory
changes
 Overflow incontinance
urine/stool
Cauda Equina Syndrome
 MRI or CT Myelography
 Neurosurgical
consultation
 Steroids + RT-
randomized controled
high dose, non-
radnomized low dose;
end treatment and 6
months in ability to
ambulate
 Radical ressection + RT
 Epidural Abcess
Other options  Staph (MRSA) 63%;
Gram Neg, Strep,
Anaerobes, TB (potts)
Sciatica  Multiple levels
 Radicular Pain  Epidurals, Surgical,
 Lateral or post leg to IVDU, Cryptogenic
foot  DM, ETOH, HIV
 Straight leg raise (10-  Pain, Fever, Weakness
60), crossed  MRI/ CT w/ gadolinium
 Numbness, no  Surgical Decompression
weakness /Aspitation
 NSAIDS  Abx: Nafcillin
(Vanc)+Flagyl+
Ceftazidime or
Cefotaxime
Should I get the imaging….?
 Progressive  IVDU
neurological
findings
 Chronic steroids
 Constitutional  HIV
symptoms (fever)  Osteoporosis
 History of traumatic  Pain > 6 weeks
onset
 History of
*American college of
malignancy radiology “Red Flags”
 Age 18 years or 50
years
Question 7
 Which of the following 1. Advanced Age
pretreatment patient 2. Increased NIHSS
characteristics has 3. Isolated global
been associated with an aphasia
increased risk of 4. Major surgery within
intracerebral 14 days
hemorrhage following 5. Rapid improvement of
treatment with TPA for neurological signs
acute ischemic stroke?
Increased Stroke Severity

Increase stroke severity via NIHSS and

increasing radiographic signs of infarct
size on CT are two independent
predictors of ICH after TPA
Tissue plasminogen activator for acute ischemic stroke.
The National Institute of Neurological Disorders and
Stroke rt-PA Stroke Study Group. NEJM. 1995 333:1581-
1587.

 Double-blind, randomized, placebo controlled

 Pts tx with rTPA are 30% more likely to have
minimal to no disability at 3 months compared
to standard care
 Increase risk of symptomatic ICH (6.4%) with
increasing NIHSS
 American Heart Association, American
Academy of Neurology, ACEP (if system in
place)
tPA
Inclusion Criteria Exclusion Criteria
Age > 18
Evidence of ICH on CT
Diagnosis of stroke with measurable deficit
History of ICH or AVM
Time of onset < 3 hours before treatment
will begin Suspected SAH with normal CT
Relative Contraindications Active internal bleeding
Major surgery or serious trauma within 2 Platelets < 100,000
weeks Heparin within 48 hours with an elevated
Only minor or rapidly improving stroke sx PTT
History of GI or GU hemorrhage within 21 Current use of oral anticoagulant with
days PT> 15sec
Recent arterial puncture as non- SBP > 185 or DBP >110 at time
compressable site treatment is to begin
Glucose >400, <50 Within 3 months any intracranial surgery,
Post MI pericarditis serious head injury, or previous
Patient with observed seizure at time of stroke (not TIA)
stroke onset
Recent Lumbar Puncture
Question 8
 A 32 year old man who lives in New England presents
complaining of bilateral leg weakness. His symptoms
began with paresthesias in his toes followed by progressive
weakness in both legs. Cranial nerve exam is normal.
Motor s 3/5 in both legs, 4/5 both arms and sensation to
light touch is mildly decreased in both legs. DTR’s are
absent in both legs and +1 in b/l arms. What is the most
likely diagnosis?
1. Lambart-Eaton Syndrome
2. Familiar periodic paralysis
3. Guillan Barre Syndrome
4. Myasthenia gravis
5. Tick paralysis
Guillain-Barre Syndrome

 Immune-mediated; motor, sensory, and

autonomic dysfunction
 GBS the most common cause of acute flaccid
paralysis in the United States
 Pure motor and motor + sensory subtypes.
 40-80% seropositive for Campylobacter jejuni
 Haemophilus influenzae, Mycoplasma
pneumoniae, and Borrelia burgdorferi. CMV,
EBV, HIV
 85% of pts with normal recovery 6-18 months
Guillain-Barre Syndrome

 Ascending weakness from proximal thighs to

trunk and upper extremities
 Cranial nerves, respiratory muscles (1/3rd)
 Paraesthesias distal to proximal,
Proprioception, sensory
 Autonomic dysfunction; HR, BP, Temp, Fecal
and urinary retention
Guillain-Barre Syndrome

 Clinical diagnosis supported by:

 Elevated or rising protein levels on serial
lumbar punctures (90% pts) 1-2 weeks
 CSF pleocytosis in HIV associated
 Cauda Equina nerve roots enhance in 85%
 ABG and FVC to assess respiratory function,
intubate for ventilatory failure
 IVIG and plasma exchange tx
Others
Myasthenia gravis
-Autoantibodies against post-synaptic Ach receptors
-Bulbar sx initialy- ptosis, diplopia, dysphagia, 1% resp
-Descending weakness
-Thymoma 10-15%
-Sx improve with rest
Lambart-Eaton Syndrome
-Autoantibodies against voltage gated calcium channels in pre-
synaptic motor nerve terminal
-Proximal lower extremity weakness (up from chair), months
-Less common bulbar findings
-Highly associated with cancer (50-70%)
-Sx improve with movement
Others
Familial periodic paralysis
-AD, variable penetrance
-Chanelopathy resulting in inexcitability of Na/Ca channels
leading to periodic flacid paralysis
-Hyperkalemic and Hypokalemic subtypes
-Worsened by heat, stress, high carbohydrate meals
Tick paralysis
-Caused by neurotoxin from salivary gland
-Ascending paralysis 1-2 weeks
-Ataxia variant
-Rock Mountain wood tick (Dermacentor andersoni) and
American dog tick (Dermacentor variabilis)
Question 9
 A 25 year old male
presents with 1 day of 1. Right brainstem
severe right sided head
and neck pain with cva
blurred blurred vision. 2. Cluster Headache
He states he went to his
chiropracter in the 3. Bells Palsy
morning before 4. Tick Bite
symptom onset. On
exam he has right sided 5. Carotid artery
miosis and ptosis with dissection
normal motor function
and sensory function.
What is his most likely
Carotid Artery Dissection
 Unilateral  Trauma
facial/neck/orbital pain  Chiropractic
 Hypoageusia manipulation
 Transient blindness,  Sports, yoga
amaurosis fugax  CTD
 50% w/ partial horners  HTN
syndrome- miosis,  Smoking
ptosis, no anhydrosis
 Oral contraceptives
 25% pulsitle tinnitus
 Neck swelling, bruise
 May progress to CVA
with dense hemiparesis
Horners Syndrome
 Sympathetic fibers run
upwards vis cervical
spine ganglia
 Bifruncate at division of
CC to IC and EC (sweat
glands)
 Innervate pupilary
dilators (dilation lag)
and lids
 Migraine, Brainstem
CVA, Pancoast tumor,
brachial plexus trauma,
Lung lesion (TB, HMX),
neuronal lesion
Diagnosis and Treatment

 Angiography gold  Anticoagulation with

standard heparin
 MRA optimal if  Neurosurgical
available consultation
 CT angiogram
evolving, esp for
trauma pts
Question 10
 A 43 year old male 1. When was the milks
presents to the expiration date?
emergency room with 2 2. Can he move his
hours onset decreased forehead?
movement of right side 3. Does he have a
of face, ear pain, and history of migraine?
thinks he might have
had spoiled milk with 4. Does he have
his cereal this am clustered vesicles
because it tasted funny. about the ear?
What is the least 5. Does he have
important question for peripheral motor
the diagnosis? weakness?
Bells Palsy- Not spoiled milk.
 Facial Nerve CN 7
palsy
 Upper and lower facial
weakness
 Post auricular pain
 Hyperacusis (stapedius)
 Hypoageusia (ant 2/3
tongue)
 Decreased lacrimation
 30% pts w/ Crocodile
tears, dysagusia, partial
paralysis; 80-90%
Bells Palsy
Causes Treatment
HSV 1,2 Prednisone 60mg/day X 7
VZV days
Mycoplasma pneumoniae Acyclovir 800mg 5X/day
Borrelia burgdorferie for 7 days
HIV (b/l) Valacylovir 1000mg TID
for 7 days
Adenovirus
Artificial Tears
coxsackievirus
Ebstein-Barr virus
Hepatitis A, B, and C
Cytomegalovirus
Bells Palsy- Treating Ourselves?
 Prednisone treatment for idiopathic facial paralysis (Bell's
palsy). N Engl J Med 1972 Dec 21; 287(25): 1268-72; 89%
pred, 64% placebo
 Cochrane Database 2002- Corticosteroids for Bell's palsy
(idiopathic facial paralysis). No sufficient support for steroids
 Cochrane Database 2004- randomized(?) trials of acylovir or
valtrex with or without steroids for treatment of bells palsy ;
insufficient evidence for support of antiviral medications
 Valacyclovir and prednisolone treatment for Bell's palsy: a
multicenter, randomized, placebo-controlled study; Otol
Neurotol. 2007 Apr;28(3):408-13. N=221; 6-8% improvement
in severity and complete remission
Ramsey-Hunt Syndrome

Herpes Zoster Oticus; HSV1, HSV2,

VZV
Triad of auricular pustules, ear pain,
ipsilateral facial paralysis
+/- Hypoaguseia and hyperacusis
Worse prognosis
Question 11
 38 y/o female with a history of epilepsy presents
with multiple seizures without return to
consciousness for 30 minutes. Her finger stick is
100 and her blood ICON is negative. The patient
has been given 4 mg of ativan X2 but continues to
seize. What is your next step?
1. 4 mg Midazolam
2. 8 mg Ativan
3. Vitamin B6
4. Fosphenytoin load
5. Succinylcholine and etomidate with ETT
Fosphenytoin Load

 Status Epilepticus
 30 minutes of seizure activity without return of
consciousness
 If seizure >4-5 minutes consider status;
neuronal injury- must wake up!
 Non-convulsive- EEG!
 Treatment of status based on universal
guidelines and institutional protocol
 Treatment and investigation parallel
Status Epilepcitcus
 1/3rd new onset Toxins
 1/3rd epilepsy  INH
 1/3rd:  Tricyclics (AVR, QRS)
 Idiopathic  Theophylline
 Hyper/hyponattremia  Cocaine
 Hypercalcemia  Sympathomimetics
 Hypoglycemia  Alcohol withdrawal
 CVA  Organophosphates
 Trauma (strychnine)
 Infectious  DM medications
 Mass (glucose)
Status Epilepticus

1st Line: Ativan 4 mg over 2 minutes q5 min X2

 If no access 20mg diazepam pr, 10mg
midazolam IM
 2nd Line: IV Fosphenytoin (20mg/kg at
150mg/min; may add 10mg/kg)
 May give IV Keppra, Valproic Acid,
Phenobarbitol if pt is on it
 3rd Line: Pentobarbitol, Intubation with
continuous drip of midazolam or propofol
 Other: Vitamin B6 (70mg/kg up to 5 )
Question 12

 A 35 year old female 1 week post-partum

presents with 1 day of severe headache,
nausea and vomiting. She is slightly confused
and lethargic. She is afebrile, normo-tensive,
with a negative UA. Given the clinical picture,
what is the treatment of choice?
1. PCC or FFP
2. Emergent Craniotomy
3. Serial lumbar punctures
4. Magnesium Sulfate IV
5. Heparin
Heparin, Venous Sinus
Thrombosis
 Headache, nausea,
emesis, ams, focal
deficits; pesudotumor
cerebri
 Women, peripartum,
hypercoaguable states,
systemic inflammatory
conditions
 CT head, MRV
 Atypical ischemic or
hemorrhagic region
 Tx: Heparin
Question 13
 A 70 year old male 1. Middle Cerebral Artery
presents to the ER with 2. Anterior Cerebral
weakness in the leg Artery
upon waking this
morning. His exam 3. Posterior Cerebral
shows left leg 2/5 Artery
strength with ataxia of 4. Basilar Artery
limb, 4/5 left arm 5. Carotid Artery
strength, no facial
droop. He keeps asking
what time it is. Where is
his lesion?
Anterior Cerebral Artery Stroke
 Affects medial parietal,
temporal, and frontal
lobes
 Contralateral Motor and
Sensory Leg > face and
arm
 Dis-inhibition,
perseveration, primitive
reflexes
Basilar Artery Stroke

 Bilateral sx
 Coma
 Locked in syndrome
Question 14
 A 23 year old patient 1. Pretreat with lidocaine and
presents is BIBEMS being consider fentanyl and
bagged with a GCS of 3. vecuronium
His friend is with him and 2. Do not allow single episode
states that while doing “a of hypoxia or hypotension
lot” of cocaine his friend 3. Hyperventilate to pC02 25-
developed severe 30
headache with sudden 4. Raise head of bed to 30
loss of conciousness. degrees
Which of the following 5. Consider manitol or
considerations in further hypertonic saline for
management is incorrect? deterioration in neurologic
status
Maintain pCO2 between 35-40,
not any lower!
Pretreatment Ventilation
 Oxygen NRB *Short term hyper-
 Lidocaine 1.5mg/kg 3 ventilation for nerologic
minutes before deterioration
 Fentayl 2ug/kg *Maintain pCO2 35-40
 Vecuronium .01mg/kg *Long term hyper-
(De-fasciculating Dose) ventilation not Rx
 Intubation by most
experienced MD; single
episode of hypoxia
associated with poor
outcome
Management of elevated ICP
 CPP=MAP-ICP  Treatment of Increased
 Maintain cerebral ICP includes:
perfusion -Mannitol
 Do not lower BP by > -Raise Head of bed 30 D
20%
-Hypertonic Saline (future)
 General rule is to
maintain systolic -Hyperventilation
between 160-180 -Surgical evacuation
 A single hypotensive
episode is assoicated
with worse outcomes
 Tx hypotension with IVF
Question 15
 A 45 year old inmate 1. Hypoglycemia
with no pmhx presents
with 1 hour of 2. Metabolic
headache, right leg and Derangement
arm paralysis, left
3. Migraine
forearm numbness,
third right toe 4. CVA
numbness, and a voice
5. All of the above
in his head telling him
that he is hungry. Which
of the following must
you concsider in your
differential?
All of the Above!
 Hypoglycemia (may be focal)
 Seizure, Todds paralysis (may
last 24 hours)
 CNS infection
 Bells Palsy (forehead
affected)
 Other Metabolic derangement
 Migraine (focal deficits
possible)
 Conversion disorder
 Malingering
 Lower CNS lesion, trauma
 Toxic
THE END

THANK YOU!
Please also read
-Parkinsons
-Dimentia
-Delerium
-Multiple Sclerosis
-Everything else!
Question 16 ? If you want more…
 A 22 year old female presents with double vision. The
symptoms disappear with either eye is covered. Extraoccular
movements are intact when tested individually. On conjugate
gaze testing there is nystagmus in the left eye and limited
adduction in the right eye. What is the most likely cause?
1. Dislocated Lense
2. Tertiary neurosyphilis
3. Internuclear Opthalmoplegia
4. Sixth Nerve palsy
5. Third Nerve palsy
Internuclear Opthalmoplegia
 Occurs due to disruption in the medial longitudinal
fasciculus (MLF)
 Corrdinates conjugate eye movements
 Most commonly due to MS
 MS occurs in young women; deficits vary anatomically
and temporally
Diplopia

Monocular Binocular
 CN palsies
 Refractive error  Brain lesions
 Dislocated lenses  HTN crisis
 Cocaine
 Iridodialysis  Wernicke’s
 SLE
 Malingering
 Retro-orbital
mass/hematoma