Neurologic Emergencies

Review test


1. A 27-year-old woman presents with severe headache, stiff neck, and general
malaise. Lumber puncture reveals a pink CSF with few white blood cells, a
normal protein, and glucose. You spin tubes 1 and 4 for cell count and obtain a
yellowish supernatant in each. Which of the following is the most likely
diagnosis?

(A) Traumatic tap
(B) Viral meningitis
(C) Subarachnoid hemorrhage
(D) Pseudotumor cerebri
(E) Tuberculous meningitis

2. which of the following findings is diagnostic for pseudotumor cerebri?

(A) Papilledema
(B) Cranial nerve II, IV, or VI palsy
(C) Relief of headache after vomiting
(D) Increased intracranial pressure per CT scan
(E) None of the above

3. A 77-year-old man with past medical history significant for hypertension and
coronary artery disease presents with sudden onset of right hemiparesis and
dysarthria, which have become progressively worse over the past 5 hours.
Which of the following is the most likely site of the lesion?

(A) Left middle cerebral artery
(B) Right middle cerebral artery
(C) Left anterior cerebral artery
(D) Right anterior cerebral artery
(E) Left vertebrobasilar artery

4. A 21-year-old woman presents with a severe left-sided headache of several
hours duration. She describes the pain as throbbing, and states that the
previous evening she noted flashing lights. She has had these headaches
before, and her mother and aunt have similar headaches. Which of the
following is the most likely diagnosis?

(A) Cluster headaches
(B) Subarachnoid hemorrhage
(C) Tension headache
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(D) Migraine headache
(E) Pseudotumor cerebri

5. A 37-year-old woman presents with sudden-onset vertigo associated with
right-sided hearing loss, nausea, vomiting, and sense of loss of balance. She
reports that she had an upper respiratory tract infection 2 weeks ago. Physical
examination reveals a unidirectional fatigable nystagmus, and decreased
hearing on her right ear. Which of the following diagnoses is most likely?

(A) Acute labyrinthitis
(B) Cerebellar pontine angle tumor
(C) Vestibular neuronitis
(D) Vertebrobasilar insufficiency
(E) Benign positional vertigo

6. A 48-year-old woman presents with acuter vertigo, nausea, vomiting, hearing
loss, and ringing in her left ear, which feels full. She has a history of such
attacks for the past 2 years. The attacks lasts about an hour and the resolves.
Which of the following diagnoses is most likely?

(A) Benign positional vertigo
(B) Recurrent otitis media
(C) Posttraumatic vertigo
(D) Menieres disease
(E) Vestibular neuronitis

7. A 33-year-old woman presents with complaints of weakness and tingling of
her left side for 3 days. Three months ago she had right eye pain and blurred
vision. One month ago she had an episode of urinary incontinence. Which of
the following diagnoses is most likely?

(A) Guillian-Barr syndrome
(B) Viral syndrome
(C) Peripheral neuropathy
(D) Transient ischemic attack
(E) Multiple sclerosis

Directions: the response option for Items 8-11 are the same. You will be required
to select one answer for each item in the set.

Questions 8-11

Match each description with the correct disease.
(A) Guillian-Barr syndrome
(B) Bells palsy
(C) Myasthenia gravis
(D) Trigeminal neuralgia


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8. Acute ascending peripheral neuropathy with symmetric limb weakness,
frequently follows a viral illness.

9. Acute unilateral severe facial pain, absence of neurologic deficits

10. Acute peripheral neuropathy with asymmetric involvement of face, often
follows a viral illness.

11. Facial muscle weakness, fatigability with repeated use


Answers and Explanations


1-C. The yellowish supernatant obtained is called xanthochromia, which is
pathognomonic for hemorrhage. This yellowish color is not to be confused with the
straw yellow color of cerebrospinal fluid (CSF) (unspun) seen in tuberculous
meningitis. A traumatic tap also may present as a pink or red CSF, but this color and
the number of red blood cells (RBCs) clear up by the last tube, and there is no
xanthochromia. See table 6-3 for more information on CSF findings in lumber
puncture.

2-E. Pseudotumor cerebri is a diagnosis of exclusion, so there are no findings that are
diagnostic or pathognomonic for it. All choices listed are features of the disease,
which is noted especially in young, overweight women. Differential diagnosis
includes other causes for increased intracranial pressure such as papillitis, malignant
hypertensive retinopathy, central retinal vein occlusion, ischemic optic neuropathy,
vasculitis of the optic disc, sarcoid or tuberculous granuloma, or other tumor.

3-A. Contralateral hemiparesis and language deficits are seen with middle cerebral
artery (MCA) lesions. Because the hemiparesis is on the right side of the body, the
lesion is on the left side of the brain. Lesions of the anterior cerebral artery also can
produce hemiparesis, but there usually are no associated language deficits.
Homonymous hemianopsia also may be seen with MCA strokes. Vertebrobasilar
artery strokes generally present with contralateral pain and temperature loss, not
motor deficit.

4-D. This patients presentation and history are typical of migraine headache. Cluster
headache is more common in men, and tension headache usually is bilateral.
Subarachnoid hemorrhage is always a possibility and should be ruled out with CT
scan and a lumber puncture if Ct scan in negative. Pseudotumor cerebri is a diagnosis
of exclusion, and usually is not accompanied by auras or family history.

5-A. The sudden onset of the vertigo and unidirectional fatigable nystagmus suggest a
peripheral cause of vertigo, which eliminates cerebellar pontine angle tumor and
vertebrobasilar insufficiency. Benign positional vertigo is a diagnosis of exclusion,
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and is more common in the elderly. This leaves acute labyrinthitis and vestibular
neuronitis. These can be distinguished by the fact that vestibular neuronitis does not
present with hearing loss, which this patient does have; therefore, the diagnosis is
acute labyrinthitis.


6-D. Menieres disease is characterized by a triad of vertigo, tinnitus, and hearing
loss. The vertigo of benign positional vertigo lasts only a few seconds, whereas in
Menieres disease it lasts for hours. Recurrent otitis media rarely produces acute
vertigo and tinnitus, and also is uncommon in this patients age group. Posttraumatic
vertigo occurs post trauma, which is irrelevant in this chronic presentation. Vestibular
neuronitis usually does not present with hearing loss.

7-E. Multiple sclerosis is best characterized by multiple neurologic deficit that cannot
be accounted for by a single lesion. This patients age and presentation are quite
typical of MS. Although MS is a diagnosis of exclusion, MRI may demonstrate
suggestive lesions and CSF studies may reveal oligoclonal bands. Guillain-Barr
syndrome is an acute ascending neuropathy that usually follows a viral illness by a
few weeks and does not match this patients history or physical examination findings.
A viral syndrome rarely produces this cluster of neurologic deficits. A peripheral
neuropathy would not result in urinary incontinence. In a transient ischemic attack,
symptoms resolve in 24 hours, by definition.

8-A. Guillain-Barr syndrome is an acute ascending peripheral neuropathy with
symmetric limb weakness, which frequently follows a viral illness

9-D. Trigeminal neuralgia is characterized by acute unilateral severe facial pain and
an absence of neurologic deficit.

10-B. Bells palsy is an acute peripheral neuropathy with asymmetric involvement of
the face, and often follows a viral illness.

11-C. Myasthenia gravis is characterized by facial muscle weakness and fatigability
with repeated use.
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