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44 Cards in this Set
- Front
- Back
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A 62-year old right handed man has transient episodes of weakness in the right hand, blurred vision, and difficulty expressing himself. There is no associated headache, the episodes have sudden onset, lasting about 5-10 minutes at the most, and they resolve spontaneously, leaving no neurologic sequelae.
What is this? |
Transient Ischemic Attack in the territory of the left carotid artery, caused by stenosis or an ulcerated plaque at the left carotid bifurcation |
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A 62-year old right handed man has transient episodes of weakness in the right hand, blurred vision, and difficulty expressing himself. There is no associated headache, the episodes have sudden onset, lasting about 5-10 minutes at the most, and they resolve spontaneously, leaving no neurologic sequelae.
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Start workup with Duplex scanning. If stenosis exceeds 70% proceed to carotid endarterectomy. |
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A 61-year old man presents with a 1-year history of episodes of vertigo, diplopia, blurred vision, dysarthria, and instability of gait. The episodes have sudden onset, last several minutes, have no associated headache, and leave no neurologic sequelae.
What is this? |
Transient ischemic attack - involvement of the vertebral arteries |
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A 61-year old man presents with a 1-year history of episodes of vertigo, diplopia, blurred vision, dysarthria, and instability of gait. The episodes have sudden onset, last several minutes, have no associated headache, and leave no neurologic sequelae.
How should this patient be managed? |
Start with Duplex scanning of the vertebral arteries |
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Last week, a 60-year old diabetic man had abrupt onset of right third nerve paralysis and contralateral hemiparesis. There was no associated headache. The patient is alert, but the neurologic deficits have not resolved.
What is this? |
"Stroke" - neurologic catastrophes that begin suddenly and have no associated headache are vascular occlusive |
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Last week, a 60-year old diabetic man had abrupt onset of right third nerve paralysis and contralateral hemiparesis. There was no associated headache. The patient is alert, but the neurologic deficits have not resolved.
How should this patient be managed? |
- Vascular surgery in the neck is designed to PREVENT strokes, not to treat them when they happen - There are very rare exceptions, but revascularization of an ischemic brain area risks making it bleed and get worse * CT scan to assess extent of infarct * Supportive treatment with emphasis on rehab - Eventually neck vessels will be evaluated with Doppler to see whether a second stroke may be prevented
- If it had been a very early stroke, where IV infusion of tPA could be started within 90 min of onset of symptoms, your choice would have been CT to rule out extensive or hemorrhagic infarct followed by tPA infusion |
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A 64-year old black man complains of a very severe headache of sudden onset and then lapses into a coma. Past medical history reveals untreated HTN and exam reveals a stuporous man with profound weakness in the left extremities.
What is this? |
"Stroke" - neurologic catastrophes of sudden onset, with severe headache, are vascular hemorrhagic - this man has bled into his head |
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A 64-year old black man complains of a very severe headache of sudden onset and then lapses into a coma. Past medical history reveals untreated HTN and exam reveals a stuporous man with profound weakness in the left extremities.
How should this patient be managed? |
- Supportive with eventual rehab efforts - CT scan is universal first choice to see blood inside head (use it in trauma for same purpose); get it to see where and how bad |
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A 39-year old woman presents to ER with a history of severe headache of sudden onset that she says is different and worse than any headache she has ever had before. Her neuro exam is completely normal, so she is given pain meds and sent home. She improves over next few days, but 10 days after initial visit she again gets a sudden, severe, and singular diffuse headache and she returns to ER. This time she has some nuchal rigidity on physical exam.
What is it? |
Subarachnoid bleeding from an intracranial aneurysm - The "sentinel bleed" that is not identified for what it is, is a common feature - The "sudden, severe, and singular" nature of pain is classic - Nuchal rigidity tells you of the presence of blood in the subarachnoid space |
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A 39-year old woman presents to ER with a history of severe headache of sudden onset that she says is different and worse than any headache she has ever had before. Her neuro exam is completely normal, so she is given pain meds and sent home. She improves over next few days, but 10 days after initial visit she again gets a sudden, severe, and singular diffuse headache and she returns to ER. This time she has some nuchal rigidity on physical exam.
How should this patient be managed? |
- Start with CT to look for blood inside head - Angiograms will eventually follow in preparation for surgery to clip the aneurysm or endovascular coiling |
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A 31-year old nursing student developed persistent headaches that began approximately 4 months ago, have been gradually increasing in intensity, and are worse in the mornings. For the past 3 weeks, she has been having projectile vomiting. Thinking she may need new glasses, she seeks help from optometrist, who discovers she has bilateral papilledema.
What is this? |
Brain tumor - neurologic processes that develop over a period of a few months and lead to increased ICP spell out tumor
Morning headaches are typical; if the tumor is in a "silent" area of the brain, there may be no other neurologic deficits |
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A 31-year old nursing student developed persistent headaches that began approximately 4 months ago, have been gradually increasing in intensity, and are worse in the mornings. For the past 3 weeks, she has been having projectile vomiting. Thinking she may need new glasses, she seeks help from optometrist, who discovers she has bilateral papilledema.
How should this patient be managed? |
- MRI is best diagnostic test (if not offered, get CT scan) - Measures to decrease ICP while awaiting surgery include high-dose steroids (Decadron) |
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A 42-year old man has a history of progressive speech difficulties and right hemiparesis for 5 months. He has had progressively severe headaches for the last 2 months. At the time of admission he is confused and vomiting and has blurred vision, papilledema, and diplopia. Shortly thereafter his BP goes up to 190/110 and he develops bradycardia.
What is this? |
Brain tumor: now with two added features, there are localizing signs (left hemisphere, parietal, temporal area) and he manifests the Cushing reflex of extremely high ICP |
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A 42-year old man has a history of progressive speech difficulties and right hemiparesis for 5 months. He has had progressively severe headaches for the last 2 months. At the time of admission he is confused and vomiting and has blurred vision, papilledema, and diplopia. Shortly thereafter his BP goes up to 190/110 and he develops bradycardia.
How should this patient be managed? |
Emergency: - MRI is best diagnostic test (if not offered, get CT scan) - Measures to decrease ICP while awaiting surgery include high-dose steroids (Decadron) |
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A 42-year old man has been fired from his job because of inappropriate behavior. For the past 2 months he has gradually developed very severe, "explosive" headaches that are located on the right side, above the eye. Neurologic exam shows optic nerve atrophy on the right, papilledema on the left, and anosmia.
What is this? |
Brain tumor: R frontal lobe
Frontal lobe has to do with behavior and social graces, and is near the optic nerve and the olfactory nerve. AKA "Foster-Kennedy syndrome". |
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A 42-year old man has been fired from his job because of inappropriate behavior. For the past 2 months he has gradually developed very severe, "explosive" headaches that are located on the right side, above the eye. Neurologic exam shows optic nerve atrophy on the right, papilledema on the left, and anosmia.
How should this patient be managed? |
MRI and neurosurgery |
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A 12-year old boy is short for his age, has bitemporal hemianopsia, and has a calcified lesion above the sella in x-rays of the head.
What is this? |
Craniopharyngioma |
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A 12-year old boy is short for his age, has bitemporal hemianopsia, and has a calcified lesion above the sella in x-rays of the head.
How should this patient be managed? |
MRI, proceed with craniotomy |
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A 23-year old nun presents with history of amenorrhea and galactorrhea of 6 months' duration. She is very concerned that others might think that she is pregnant, and she vehemently denies such a possibility.
What is this? |
Prolactinoma |
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A 23-year old nun presents with history of amenorrhea and galactorrhea of 6 months' duration. She is very concerned that others might think that she is pregnant, and she vehemently denies such a possibility.
How should this patient be managed? |
- Confirm she is not pregnant or hypothyroid - Measure the appropriate hormone (since you suspect a functioning tumor of an endocrine gland) - here check prolactin - MRI is best to see the tumor - Bromocriptine therapy is favored by most, with surgery reserved for those who do not respond or who wish to become pregnant |
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A 44-year old man is referred for treatment of HTN. His physical appearance is impressive: he has big, fat, sweaty hands, large jaw, and thick lips, a large tongue, and huge feet. He is also found to have a touch of diabetes. In further questioning he admits to headaches and he relates that his wedding ring no longer fits his finger.
What is this? |
Acromegaly - Appearance is so striking the vignette will likely come with a picture (or two: front including his hands and lateral showing the large jaw) |
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A 44-year old man is referred for treatment of HTN. His physical appearance is impressive: he has big, fat, sweaty hands, large jaw, and thick lips, a large tongue, and huge feet. He is also found to have a touch of diabetes. In further questioning he admits to headaches and he relates that his wedding ring no longer fits his finger.
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- Somatomedin C determination - MRI - Eventually pituitary surgery or radiation therapy |
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A 15-year old girl has gained weight and become "ugly". She shows a picture of herself taken a year ago, where she was a lovely young lady. Now she has a hairy, red, round face full of pimples; her neck has a posterior hump, and her supraclavicular areas are round and convex. She has a fat trunk and thin extremities. She has mild diabetes and HTN.
What is this? |
Cushing - This one will also come with a picture, rather than a description (or two pictures - before and after) |
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A 15-year old girl has gained weight and become "ugly". She shows a picture of herself taken a year ago, where she was a lovely young lady. Now she has a hairy, red, round face full of pimples; her neck has a posterior hump, and her supraclavicular areas are round and convex. She has a fat trunk and thin extremities. She has mild diabetes and HTN.
How should this patient be managed? |
- Overnight low dose dexamethasone suppression test - If no suppression --> 24 hour urinary cortisol - If cortisol is high --> high dose dexamethasone suppression test
- If suppression at high dose --> MRI of sella --> trans-sphenoidal pituitary surgery |
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A 27-year old woman develops a severe headache of sudden onset, making her stuporous. She is taken to the hospital, where she is found at admission to have a BP of 75/45. Fundoscopic exam shows bilateral pallor of optic nerves. Relatives indicate for the past 6 months, she has been complaining of morning headaches, loss of peripheral vision, and amenorrhea. After she developed the severe headache, and just before she went into a deep stupor, she told her relatives that her peripheral vision had suddenly deteriorated even more than before.
What is this? |
Pituitary apoplexy (bled into a pituitary tumor) |
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A 27-year old woman develops a severe headache of sudden onset, making her stuporous. She is taken to the hospital, where she is found at admission to have a BP of 75/45. Fundoscopic exam shows bilateral pallor of optic nerves. Relatives indicate for the past 6 months, she has been complaining of morning headaches, loss of peripheral vision, and amenorrhea. After she developed the severe headache, and just before she went into a deep stupor, she told her relatives that her peripheral vision had suddenly deteriorated even more than before.
How should this patient be managed? |
- Steroid replacement is urgently needed - Other hormones will need to be replaced eventually - MRI or CT scan will determine extent of problem |
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A 32-year old man complains of progressive, severe generalized headaches that began 3 months ago, are worse in the mornings, and lately have been accompanied by projectile vomiting. He has lost his upper gaze and he exhibits the physical finding known as "sunset eyes".
What is this? |
Tumor of the Pineal Gland - aka "Parinaud syndrome" |
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A 32-year old man complains of progressive, severe generalized headaches that began 3 months ago, are worse in the mornings, and lately have been accompanied by projectile vomiting. He has lost his upper gaze and he exhibits the physical finding known as "sunset eyes".
How should this patient be managed? |
- MRI to start - Neurosurgeons will finish |
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A 6-year old boy has been stumbling around the house and complaining of severe morning headaches for the past several months. While waiting in the office to be seen, he assumes the knee-chest position as he holds his head. Neuro exam demonstrates truncal ataxia.
What is this? |
Tumor of the posterior fossa. Most brain tumors in children are located there, and cerebellar function is affected. |
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A 6-year old boy has been stumbling around the house and complaining of severe morning headaches for the past several months. While waiting in the office to be seen, he assumes the knee-chest position as he holds his head. Neuro exam demonstrates truncal ataxia.
How should this patient be managed? |
- MRI - Neurosurgery |
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A 23-year old man develops severe headaches, seizures, and projectile vomiting over a period of 2 weeks. He has low-grade fever, and was recently treated for acute otitis media and mastoiditis.
What is this? |
Brain abscess: - Signs and symptoms suggestive of brain tumor that develop in a couple of weeks with fever and an obvious source of infection |
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A 23-year old man develops severe headaches, seizures, and projectile vomiting over a period of 2 weeks. He has low-grade fever, and was recently treated for acute otitis media and mastoiditis.
How should this patient be managed? |
- CT (cheaper, easier) is best - MRI also an option - Abscess needs to be resected |
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What is this? |
Most tumors affecting the spinal cord are metastatic and extradural.
In this case the source is obvious, and the sudden onset of paralysis suggests a fracture with cord compression or transection. |
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A 52-year old woman has constant, severe back pain for 2 weeks. While working in her yard, she suddenly falls and cannot get up again. When brought to the hospital she is paralyzed below the waist. Two years ago she had a mastectomy for cancer of the breast.
How should this patient be managed? |
- Typically an x-ray of affected area is done right away, and will show a huge, bony metastasis and the fracture that it has produced - Best imaging to see the cord (transected? compressed?) is the MRI - Neurosurgeons may be able to help if the cord is compressed rather than transected |
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A 45-year old man gives a history of aching back pain for several months. He has been told that he had muscle spasms, and was given analgesics and muscle relaxants. He comes in now because of the sudden onset of very severe back pain that came on when he tried to lift a heavy object. The pain is "like an electrical shock that shoots down his leg," it is worse with sneezing and straining, and it prevents him from ambulating. He keeps the affected leg flexed. Straight leg raising test gives excruciating pain.
What is this? |
Lumbar disk herniation - Peak age of incidence is 45 - Virtually all occur at L4-L5 or L5-S1 - If the "lightning" exits the foot by the big toe, it is L4-L5; if it exits by the little toe it is L5-S1 |
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A 45-year old man gives a history of aching back pain for several months. He has been told that he had muscle spasms, and was given analgesics and muscle relaxants. He comes in now because of the sudden onset of very severe back pain that came on when he tried to lift a heavy object. The pain is "like an electrical shock that shoots down his leg," it is worse with sneezing and straining, and it prevents him from ambulating. He keeps the affected leg flexed. Straight leg raising test gives excruciating pain.
How should this patient be managed? |
- MRI for diagnosis - Bed rest and pain control will take care of most cases - Neurosurgical treatment only if progressive weakness or sphincteric deficits |
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A 79-year old man complains of leg pain brought about by walking and relieved by rest. On further questioning it is ascertained that he has to sit down or bend over for the pain to go away. Standing at rest will not do it. Furthermore, he can exercise for long periods of time if he is "hunched over" such as riding a bike or pushing a shopping cart. He has normal pulses in his legs.
What is this? |
Neurogenic Claudication - Disease is Spinal Stenosis |
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A 79-year old man complains of leg pain brought about by walking and relieved by rest. On further questioning it is ascertained that he has to sit down or bend over for the pain to go away. Standing at rest will not do it. Furthermore, he can exercise for long periods of time if he is "hunched over" such as riding a bike or pushing a shopping cart. He has normal pulses in his legs.
How should this patient be managed? |
- Get MRI and refer to pain clinic - Pain control can usually be obtained with steroid and analgesic injections under x-ray guidance - Surgery is rarely needed |
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A business exec who has been a T6 paraplegic for many years is held at a business meeting for several hours beyond the time when he would normally have done his in-and-out self catheterization of the urinary bladder. He develops a pounding headache, profuse perspiration, and bradycardia. His BP is 220/120.
What is this? |
Autonomic Dysreflexia |
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A business exec who has been a T6 paraplegic for many years is held at a business meeting for several hours beyond the time when he would normally have done his in-and-out self catheterization of the urinary bladder. He develops a pounding headache, profuse perspiration, and bradycardia. His BP is 220/120.
How should this patient be managed? |
- Bladder needs to be emptied - He also needs alpha-adrenergic blocking agents and may benefit from calcium-channel blockers (such as nifedipine) |
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A 60-year old man complains of extremely severe, sharp, shooting, "like a bolt of lightning" pain in his face that is brought about by touching a specific area and which lasts about 60 seconds. His neuro exam is normal but it is noted that part of his face is unshaven because he fears to touch that area.
What is this? |
Tic Douloureux (trigeminal neuralgia) |
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A 60-year old man complains of extremely severe, sharp, shooting, "like a bolt of lightning" pain in his face that is brought about by touching a specific area and which lasts about 60 seconds. His neuro exam is normal but it is noted that part of his face is unshaven because he fears to touch that area.
How should this patient be managed? |
Rule out organic lesions with MRI. Treat with anti-convulsants. |
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Several months after sustaining a crushing injury of his arm, a patient complains bitterly about constant, burning, agonizing pain that does not respond to the usual analgesic meds. The pain is aggravated by the slightest stimulation of the area. The arm is cold, cyanotic, and moist.
What is this? |
Causalgia (reflex sympathetic dystrophy) |
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Several months after sustaining a crushing injury of his arm, a patient complains bitterly about constant, burning, agonizing pain that does not respond to the usual analgesic meds. The pain is aggravated by the slightest stimulation of the area. The arm is cold, cyanotic, and moist.
How should this patient be managed? |
- Successful sympathetic block is diagnostic - Surgical sympathectomy will be curative |
