AOA Neuro Review

Clinical Aspect

April, 2010

Question

A 72-YO F suddenly dies at home from cardiac arrest secondary to V. fib. Autopsy reveals numerous small infarcts throughout basal ganglia. Assuming only one vessel is involved, which of the following would be most consistent with these findings?

A. Anterior Cerebral ArteryB. Anterior Communicating ArteryC. Lateral Striate ArteryD. Posterior Cerebral ArteryE. Middle Cerebral Artery

Answer: Choice C

Lateral Striate artery: aka “arteries of stroke”– Supply internal capsule, caudate, putamen and

globus pallidus– Usually involved in the setting of chronic HTN and

DM, causing the famous “lacunar infarcts”

MCA can be correct, but look for most specific answer.

Question

49-YO M presents with dysarthria and progressive muscle weakness of b/l U+L extremities. No hx of neurological disease. PE notable for muscle atrophy and weakness in all extremities. DTR absent in upper ext. and 3+ in lower ext. Some fasciculations and + Babinski’s b/l. CN intact and all labs/imaging are nl. What would you expect to find on microscopic examination?

A. Demyelination of dorsal columns and spinocerebellar tracts.

B. Demyelination of post. limb of internal capsule.C. Neuronal loss in region of ant. horn cells and corticospinal

tracts in spinal cord.D. Neuronal loss in region of ant. horn cells and post. column

of spinal cord.E. Neuronal loss in region of ant. horn cells only.

Answer: Choice C

Dx: Amyotrophic Lateral Sclerosis (ALS)– Affects both ant. horn cells and upper motor neurons

combo of both upper and lower motor neuron signs. – Only current Tx: Riluzole

Choice A: Think Vit. B12 Neuropathy Choice D: Think Charcot-Marie-Tooth Disease aka

Peroneal Muscle Atrophy Choice E: Think Poliomyelitis (viral infection the

causes pure lower motor neuron disease flaccid paralysis)

Question

70-YO F has 3-yr-hx of worsening LBP that radiates over ant. thighs. Worse with walking/standing and relief with rest/sitting. Also c/o decreased urinary stream. PE shows decreased lumbar mobility and (-) straight leg test b/l. 2+ pulses b/l and 1+ ankle reflexes b/l. Which of the following is most likely?

A. Conus medullaris syndromeB. Lumbar spinal stenosisC. Lumbosacral disc herniationD. Peripheral vascular diseaseE. PMRF. Claudication

Answer: Choice B

Lumbar spinal stenosis: Common in aging population due to lumbar disc degeneration with enlargement of facet joints.

– Classic Neurogenic Claudication (differs from claudication as max pain over ant. thigh rather than legs)

– Usually have preserved pulses (unlike PVD)

Choice A: Cord compression syndrome that produces perianal numbness and urinary retention w/ atonic rectal sphincter.

Question

41-YO M presents to ED with 2-day-hx of vision problems. He has AIDS and informs physician that last CD4 count 3 mo. ago was 24 cells/micro liter. He stopped taking medication 2 years ago. Neuro exam shows speech, memory, and coordination problems. Admitted, but he worsens, and dies 3 wks later. What is most likely cause?

A. Cryptococcus neoformansB. HSVC. JC VirusD. Pneumocystis jiroveciE. Toxoplasmosa gondii

Answer: Choice C

Dx: Progressive Multifocal Leukoencephalopathy (PML)

– Reactivation of dormant virus– Very rapid causes multiple areas of demyelination in

white matter Choice A: AIDS/HIV Meningitis Choice B: AIDS temporal lobe encephalitis Choice D: AIDS pneumonia with classic “ground

glass” CXR Choice E: Most common cause of AIDS encephalitis

ring-enhancing lesion with sz and HA

Question

26-YO M comes to ED c/o new-onset HA and blurry vision of one hour duration. HA is generalized and suddenly began while patient was having intercourse. No previous episodes. Appears very nervous. + Hx of drug abuse. Which of the following hemorrhages is most likely?

A. EpiduralB. IntraduralC. ParenchymalD. SubarachnoidE. Subdural

Answer: Choice D

Subarachnoid: aka “worst headache of my life”– Always think of drug-induced SAH in younger adults (esp.

cocaine-induced)

Choice A: Usually severe head trauma + damage to MMA

Choice C: Usually with chronic HTN in elderly Choice E: Usually elderly falling and damaging

bridging veins.

Question

2-wk-old full term baby girl is found to have a tuft of hair on lower back during first appointment. No lesion is found. US shows no herniation. No other findings on PE. Which of the following conditions could this be?

A. AnencephalyB. MeningoceleC. MeningomyeloceleD. Spina bifida cysticaE. Spina bifida occultaF. Normal variant

Answer: Choice E

Sb occulta: due to failure of posterior vertebral arches to close. Usually, NO assoc. clinical abnormalities.

Sb cystica: due to failure of posterior vertebral arches to close, ALONG with protrusion of a saclike structure

Choice A: Usually w/o forebrain and cerebrum w/ exposed brain

Question

41-YO F comes to PCP for regular checkup. On neuro exam, when she looks to the left, right eye stops at midline and left eye shows monocular horizontal nystagmus. No problems looking right. Normal convergence. What is most likely cause?

A. Internuclear ophthalmoplegiaB. Medial rectus damageC. Sixth-nerve palsyD. Medial Longitudinal Fasciculus PalsyE. Positional Nystagmus

Answer: Choice A

INO: Very common in MS population due to damage of ipsilateral MLF, which is connection b/w abducent and oculomotor nuclei.

Choice B: permanent “down and out” eye Choice C: would almost be opposite Choice D: No such thing Choice E: possible but not best answer

Question

58-YO homeless F brought to the ED by police, who is disoriented and confused. Patient has problems with short-term memory. She provides plausible details of events, which police report to be untrue. On PE, she is emaciated w/ nystagmus and unsteady gait. Can smell alcohol on her breath. Which of the following areas account for these findings?

A. Basal gangliaB. Broca’s areaC. Cerebellar vermisD. Mamillary bodiesE. Wernicke’s areaF. Crus cerebri

Answer: Choice D

Dx: Wernicke-Korsakoff encephalopathy thiamine deficiency in chronic ETOH abusers.

– Have confusion, disorientation, anterograde amnesia, confabulation, oculomotor dysfunction, and motor ataxia.

Choice A: Assoc. w/ movement disorder Choice B: Assoc. w/ motor aphasia w/ good

comprehension Choice C: Assoc. w/ truncal ataxia and dysarthria Choice E: Assoc. w/ sensory aphasia w/ poor

comprehension

Question

During a right temporal craniotomy, the neuronal radiations projecting to the inferior bank of the calcarine sulcus are injured. Which of the following is the most likely visual disturbance?

A. Lt upper quadrantanopiaB. Lt hemianopia with macular sparingC. Lt lower quadrantanopiaD. Rt upper quadrantanopiaE. Rt hemianopia with macular sparingF. Rt lower quadrantanopia

Answer: Choice A

Temporal lobe lesion damages lower division of the geniculocalcarine tract, aka Meyer’s Loop represent superior visual field quadrants.– Since lesion is behind optic chiasm, deficit is

contralateral. Hemianopia w/ Macular Sparing injury to

visual cortex (located on banks of calcarine fissure)

Question

36-YO F presents with 4-mo-hx of episodic nausea and sensation of abnl motion that lasts for 4-5 min. Symptoms have worsened w/ time. Now has vomiting and buzzing in right ear lasting longer than an hour. PE shows mild sensorineural hearing loss in rt ear. Audiologic tests shows rt-sided hearing loss, most pronounced in low-frequency range. Which of following is most likely origin of abnormality?

A. CochleaB. Endolymphatic sacC. Semicircular canalsD. Utricle and sacculeE. Vestibulocochlear nerve

Answer: Choice B

Vertigo lasting more than an hour think either migraine or Meniere’s disease.

– Distinguish with auditory dysfunction– Meniere’s: Have progressive low-frequency hearing loss w/

aural fullness and tinnitus. Due to increase in volume of endolymphatic system secondary to malfunction of sac.

Choice C: Think BPPV (lasts for seconds) Choice D: More involved w/ accel/decel. Causes one

to feel tilted leading to falls.

QUESTIONS?