1. Neurology Board Review

2. Question 1
A 72 year old man presents with acute onset vertigo, nystagmus, dysphagia, and horners syndrome. The most likely diagnosis is?

3. Your Choices…. 1. Acute Labryinthitis
2. Benign paroxysmal positional vertigo
3. Lateral Medullary Infarction
4. Opthalmoplegic Migraine

4. Lateral Medullary Infarction!
AKA Wallenberg Syndrome
Ipsilateral face
Pain and Temperature
Dysphagia
Dysarthria
Nystagmus
+/- limb ataxia
Contralateral Limbs
-Lateral Spinothalamic tract

5. Posterior Circulation Strokes
The 5 D’s of Brainstem
Dysphagia
Dysarthria
Diplopia
Dystaxia
Dizziness
Syncope/ Drop attack
Ipsilateral Face, Contralateral Extremity
Visual Field Deficits

6. Vertigo Peripheral -Sudden -Tinnitus, Auditory -Severe n/v/dizzy
-Horizontal Nystagmus
-May be positional, recent infections
Central
-Insidious
-No peripheral sx
-Less severe n/v/dizzy
-Vertical or Horizontal Nystagmus
-Not positional, may have peripheral neuro deficits

7. 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?
Basilar Artery Occlusion
Subarachnoid Hemorrhage
Lacunar Infarction
Middle Cerebral Artery Occlusion
Posterior Cerebral Artery Occlusion

8. 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!

9. CT Finding with MCA Occlusion
Hyperdense MCA sign
Loss of cortical ribbon
Sulcal Effacement
Obscuration of the grey/white junction

10. The Wrong Answers! Basilar Artery Occlusion: Locked In
Subarachnoid Hemorrhage: HA
Lacunar Infarction: Pure motor or sensory
Posterior Cerebral Artery Occlusion: Primary visual disturbances

11. 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.

12. Question 3
What is the most common etiology for the diagnosis revealed by the CT scan?
1. AVM
2. Cavernous Angioma
3. Mycotic Aneurism
4. Neoplasm
5. Saccular Aneurysm

13. Saccular Aneurysm
80% of non-traumatic SAH are associated with saccular aneurysm
5% of the population have aneurysms; increase risk of rupture includes-
Smoking
EtOH
Stimulant Abuse
Uncontrolled HTN

14. 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

15. Cranial Nerve 6 (abducens) palsy; lateral rectus; ACOM
Cranial Nerve 3 (occulomotor) palsy; ptosis, medial, superior, inferior gaze, pupillary constrictors; PCOM
Subhyaloid Hemorrhage

16. 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?
Anterior Cerebral Artery Embolism
Internal Capsule Intracerebral Hemorrhage
Posterior Cerebral Artery Rupture
Posterior Cerebral Artery Thrombosis
Vertebral Artery Occlusion

17. 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

18. 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

19. 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

20. ICH GCS 3-4 2 5-12 1 ___________13-15 0 ICH Vol >30 1
___________
ICH Vol >
___________<
IVH Yes
___________No
Infratentoral Yes
Age >
___________<
0-6

21. 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?
Anxiety or who cares. Let him go AMA
Is he tolerating PO? Give him some reglan and get him out.
I think he is delirious. Give him some haldol and call psych.
I think he is having a reaction to the med. Lets give him Prochlorperazine. Right?
I think he is having a reaction to the med. Lets give him some Benztropine.

22. 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)
2 minutes to work, sx gone in 15

23. Question 6 1. Stroke 2. Sciatica 3. Cauda Equina Syndrome
A 65 year old male with DM, HTN, BPH, recent diagnosis of sciatica p/w 2 days of progressive difficult ambulation with worsening back pain radiating down to left leg. Exam is noteable for hyporeflexia with downgoing toes, +4/5 lower extremity strength, saddle paresthesia, and deminished rectal tone.
1. Stroke
2. Sciatica
3. Cauda Equina Syndrome
4. Acute back pain
5. Spinal Abcess

24. 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

25. 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

26. Other options Epidural Abcess Sciatica Radicular Pain
Staph (MRSA) 63%; Gram Neg, Strep, Anaerobes, TB (potts)
Multiple levels
Epidurals, Surgical, IVDU, Cryptogenic
DM, ETOH, HIV
Pain, Fever, Weakness
MRI/ CT w/ gadolinium
Surgical Decompression /Aspitation
Abx: Nafcillin (Vanc)+Flagyl+
Ceftazidime or Cefotaxime
Other options
Sciatica
Radicular Pain
Lateral or post leg to foot
Straight leg raise (10-60), crossed
Numbness, no weakness
NSAIDS

27. Should I get the imaging….?
Progressive neurological findings
Constitutional symptoms (fever)
History of traumatic onset
History of malignancy
Age 18 years or 50 years
IVDU
Chronic steroids
HIV
Osteoporosis
Pain > 6 weeks
*American college of radiology “Red Flags”

28. Question 7
Which of the following pretreatment patient characteristics has been associated with an increased risk of intracerebral hemorrhage following treatment with TPA for acute ischemic stroke?
Advanced Age
Increased NIHSS
Isolated global aphasia
Major surgery within 14 days
Rapid improvement of neurological signs

29. 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

30. Double-blind, randomized, placebo controlled
Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. NEJM :
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)

31. tPA Exclusion Criteria Evidence of ICH on CT History of ICH or AVM
Inclusion Criteria
Age > 18
Diagnosis of stroke with measurable deficit
Time of onset < 3 hours before treatment will begin
Relative Contraindications
Major surgery or serious trauma within 2 weeks
Only minor or rapidly improving stroke sx
History of GI or GU hemorrhage within 21 days
Recent arterial puncture as non-compressable site
Glucose >400, <50
Post MI pericarditis
Patient with observed seizure at time of stroke onset
Recent Lumbar Puncture
Exclusion Criteria
Evidence of ICH on CT
History of ICH or AVM
Suspected SAH with normal CT
Active internal bleeding
Platelets < 100,000
Heparin within 48 hours with an elevated PTT
Current use of oral anticoagulant with PT> 15sec
SBP > 185 or DBP >110 at time treatment is to begin
Within 3 months any intracranial surgery, serious head injury, or previous stroke (not TIA)

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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)

38. Question 9 Right brainstem cva Cluster Headache Bells Palsy Tick Bite
A 25 year old male presents with 1 day of severe right sided head and neck pain with blurred blurred vision. He states he went to his chiropracter in the morning before symptom onset. On exam he has right sided miosis and ptosis with normal motor function and sensory function. What is his most likely diagnosis?
Right brainstem cva
Cluster Headache
Bells Palsy
Tick Bite
Carotid artery dissection

39. Carotid Artery Dissection
Unilateral facial/neck/orbital pain
Hypoageusia
Transient blindness, amaurosis fugax
50% w/ partial horners syndrome- miosis, ptosis, no anhydrosis
25% pulsitle tinnitus
Neck swelling, bruise
May progress to CVA with dense hemiparesis
Trauma
Chiropractic manipulation
Sports, yoga
CTD
HTN
Smoking
Oral contraceptives

40. 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

41. Diagnosis and Treatment
Angiography gold standard
MRA optimal if available
CT angiogram evolving, esp for trauma pts
Anticoagulation with heparin
Neurosurgical consultation

42. Question 10
A 43 year old male presents to the emergency room with 2 hours onset decreased movement of right side of face, ear pain, and thinks he might have had spoiled milk with his cereal this am because it tasted funny. What is the least important question for the diagnosis?
When was the milks expiration date?
Can he move his forehead?
Does he have a history of migraine?
Does he have clustered vesicles about the ear?
Does he have peripheral motor weakness?

43. 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% without sig deficit

44. Bells Palsy Causes HSV 1,2 VZV Mycoplasma pneumoniae
Borrelia burgdorferie
HIV (b/l)
Adenovirus
coxsackievirus
Ebstein-Barr virus
Hepatitis A, B, and C
Cytomegalovirus
Treatment
Prednisone 60mg/day X 7 days
Acyclovir 800mg 5X/day for 7 days
Valacylovir 1000mg TID for 7 days
Artificial Tears

45. Bells Palsy- Treating Ourselves?
Prednisone treatment for idiopathic facial paralysis (Bell's palsy). N Engl J Med 1972 Dec 21; 287(25): ; 89% pred, 64% placebo
Cochrane Database Corticosteroids for Bell's palsy (idiopathic facial paralysis). No sufficient support for steroids
Cochrane Database 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 Apr;28(3): N=221; 6-8% improvement in severity and complete remission

46. Ramsey-Hunt Syndrome Herpes Zoster Oticus; HSV1, HSV2, VZV
Triad of auricular pustules, ear pain, ipsilateral facial paralysis
+/- Hypoaguseia and hyperacusis
Worse prognosis

47. 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?
4 mg Midazolam
8 mg Ativan
Vitamin B6
Fosphenytoin load
Succinylcholine and etomidate with ETT

48. 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

49. Status Epilepcitcus Toxins INH Tricyclics (AVR, QRS) Theophylline
1/3rd new onset
1/3rd epilepsy
1/3rd:
Idiopathic
Hyper/hyponattremia
Hypercalcemia
Hypoglycemia
CVA
Trauma
Infectious
Mass HE
Toxins
INH
Tricyclics (AVR, QRS)
Theophylline
Cocaine
Sympathomimetics
Alcohol withdrawal
Organophosphates (strychnine)
DM medications (glucose)

50. 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 )

51. 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?
PCC or FFP
Emergent Craniotomy
Serial lumbar punctures
Magnesium Sulfate IV
Heparin

52. 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

53. Question 13
A 70 year old male presents to the ER with weakness in the leg upon waking this morning. His exam shows left leg 2/5 strength with ataxia of limb, 4/5 left arm strength, no facial droop. He keeps asking what time it is. Where is his lesion?
Middle Cerebral Artery
Anterior Cerebral Artery
Posterior Cerebral Artery
Basilar Artery
Carotid Artery

54. Anterior Cerebral Artery Stroke
Affects medial parietal, temporal, and frontal lobes
Contralateral Motor and Sensory Leg > face and arm
Dis-inhibition, perseveration, primitive reflexes

55. Basilar Artery Stroke
Bilateral sx
Coma
Locked in syndrome

56. Question 14
A 23 year old patient presents is BIBEMS being bagged with a GCS of 3. His friend is with him and states that while doing “a lot” of cocaine his friend developed severe headache with sudden loss of conciousness. Which of the following considerations in further management is incorrect?
Pretreat with lidocaine and consider fentanyl and vecuronium
Do not allow single episode of hypoxia or hypotension
Hyperventilate to pC
Raise head of bed to 30 degrees
Consider manitol or hypertonic saline for deterioration in neurologic status

57. Maintain pCO2 between 35-40, not any lower!
Pretreatment
Oxygen NRB
Lidocaine 1.5mg/kg 3 minutes before
Fentayl 2ug/kg
Vecuronium .01mg/kg (De-fasciculating Dose)
Intubation by most experienced MD; single episode of hypoxia associated with poor outcome
Ventilation
*Short term hyper-ventilation for nerologic deterioration
*Maintain pCO
*Long term hyper-ventilation not Rx

58. Management of elevated ICP
CPP=MAP-ICP
Maintain cerebral perfusion
Do not lower BP by > 20%
General rule is to maintain systolic between
A single hypotensive episode is assoicated with worse outcomes
Tx hypotension with IVF
Treatment of Increased ICP includes:
-Mannitol
-Raise Head of bed 30 D
-Hypertonic Saline (future)
-Hyperventilation
-Surgical evacuation

59. Question 15 Hypoglycemia Metabolic Derangement Migraine CVA
A 45 year old inmate with no pmhx presents with 1 hour of headache, right leg and arm paralysis, left forearm numbness, third right toe numbness, and a voice in his head telling him that he is hungry. Which of the following must you concsider in your differential?
Hypoglycemia
Metabolic Derangement
Migraine
CVA
All of the above

60. 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

61. THE END THANK YOU! Please also read -Parkinsons -Dimentia -Delerium
-Multiple Sclerosis
-Everything else!

62. 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

63. 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
Each gaze center passes inputs to ipsilateral cranial nerves and sends a contralateral input through MLF to CN 3. Lesions can be unilateral or bilateral

64. Diplopia Monocular Refractive error Dislocated lenses Iridodialysis
Malingering
Binocular
CN palsies
Brain lesions
HTN crisis
Cocaine
Wernicke’s
SLE
Retro-orbital mass/hematoma
Binoccular= disappears when either eye is covered