Neurology – Exam I – Case Studies (n.d.) – Clinical case-based study
guide and exam preparation material
1. A 6-year-old boy is struck by a car while riding his bicycle. He is reported to be unconscious
for
2 minutes following the accident. He is conscious and alert upon arrival to the emergency
department, but within 45 minutes he begins to vomit and shortly thereafter he becomes
completely unresponsive. Which of the following most likely explains this child's injury?
(A) spinal cord transection
(B) chronic subdural hematoma
(C) acute epidural hematoma
(D) acute subarachnoid hemorrhage
(E) grade III concussion - correct answer ✔✔(C) This is the classic history of an epidural
hematoma. The typical presentation is that of a child
who sustains a hard blow to the head and experiences a brief loss of consciousness, followed by
a lucid interval, when the child is awake and alert. As the hematoma expands, the patient
experiences a headache followed by vomiting, lethargy, and hemiparesis and may progress to
coma if left untreated. This injury usually results from a temporal bone fracture with a
laceration
of the middle meningeal artery or vein and less often a tear in a dural venous sinus. Epidural
hematomas are treated with surgical evacuation of the clot and ligation of the bleeding vessel.
Spinal cord transection should not present initially as a loss of consciousness and will affect
distal motor and sensory function. Chronic subdural hematomas present more than 20 days
after
the trauma. Subarachnoid hemorrhage typically presents as a generalized headache without
associated trauma. A grade III concussion usually involves continued improvement after
consciousness is gained. The lucid period followed by worsening symptoms in this question is
,worrisome of more severe intracranial pathology. (Aminoff et al., 2005, p. 329)
2. A 75-year-old man is involved in a motor vehicle accident and strikes his forehead on the
windshield. He complains of neck pain and severe burning in his shoulders and arms. His
physical examination reveals weakness of his upper extremities. What type of spinal cord injury
does this patient have?
(A) anterior cord syndrome
(B) central cord syndrome
(C) Brown-Séquard syndrome
(D) complete cord transection
(E) cauda equina syndrome - correct answer ✔✔(B) The central cord syndrome involves loss of
motor function that is more severe in the upper
extremities than in the lower extremities, and is more severe in the hands. There is typically
hyperesthesia over the shoulders and arms. Anterior cord syndrome presents with paraplegia or
quadriplegia, loss of lateral spinothalamic function with preservation of posterior column
function. Brown-Séquard syndrome consists of weakness and loss of posterior column function
on one side of the body distal to the lesion with contralateral loss of lateral spinothalamic
function one to two levels below the lesion. Complete cord transection would affect motor and
sensory function distal to the lesion. Cauda equina syndrome typically presents as low back pain
with radiculopathy. (Hauser and Ropper, 2008, p. 2580)
3. A 41-year-old woman presents to the emergency department complaining of a sudden onset
of the
"worst headache of my life." A stat computed tomography (CT) scan of her head is found to be
normal. The next appropriate step in the diagnosis of this patient would be
(A) outpatient magnetic resonance imaging (MRI) of the brain
(B) complete blood cell count (CBC) with differential
,(C) injection of sumatriptan (Imitrex)
(D) lumbar puncture
(E) repeat CT scan in 48 hours - correct answer ✔✔(D) The hallmark of a subarachnoid
hemorrhage is the very sudden onset of a severe headache.
The headache is often described as the "worst headache of my life." A CT scan will detect a
subarachnoid hemorrhage in more than 95% of cases. When the history suggests subarachnoid
hemorrhage and the CT scan fails to detect bleeding, a lumbar puncture is mandatory. The
lumbar
puncture will yield bloody cerebrospinal fluid in subarachnoid hemorrhage. Outpatient MRI or
repeat CT scan in 48 hours would create a potentially harmful delay in diagnosis. CBC with
differential may be ordered but will not confirm the suspected diagnosis. Treatment with
Imitrex
is contraindicated in the presence of a potential cerebrovascular syndrome. (Hemphill and
Smith, 2008, p. 1728)
4. A 45-year-old woman with a known seizure disorder has been noncompliant with her anti-
convulsant medication due to side effects she has been experiencing. While in your office, she
starts convulsing at a frequency that does not allow consciousness. Which of the following is the
most appropriate initial drug treatment?
(A) lorazepam
(B) phenytoin
(C) phenobarbital
(D) valproic acid - correct answer ✔✔(A) Status epilepticus, defined as a continuous seizure or
repeated seizures in which interval
consciousness is not obtained, is a medical emergency. An intravenous infusion of a longer
acting
benzodiazepine, such as lorazepam, has been shown to be effective in terminating a seizure. If
the
seizures persist, then other potential agents to use after the initial lorazepam infusion include
, fosphenytoin (phenytoin) or valproic acid (phenobarbital). (Lowenstein, 2008, p. 2511)
5. While performing a routine history and physical examination on a 70-year-old man, you note
a
right carotid bruit. He denies any symptoms suggestive of a transient ischemic attack (TIA) or
cerebrovascular accident. A carotid Doppler ultrasound shows a 50% stenosis of the right
common carotid artery. The next most appropriate step would be
(A) stat carotid arteriogram
(B) initiate antiplatelet therapy with aspirin
(C) anticoagulate with warfarin
(D) intra-arterial tissue plasminogen activator (t-PA)
(E) carotid endarterectomy - correct answer ✔✔(B) The patient exhibits an asymptomatic
carotid bruit. The most appropriate step would be to initiate antiplatelet therapy with daily
aspirin. Arteriography would not be indicated for an
asymptomatic carotid bruit. Anticoagulation with warfarin (Coumadin) should be limited to
symptomatic bruits manifested as multiple TIAs. Carotid endarterectomy is reserved for carotid
stenosis that is greater than 70% in patients who have had recurrent TIAs on medical therapy.
(Aminoff et al., 2005, pp. 308-310)
6. A cerebrospinal fluid analysis reveals the following results: opalescent color, increased
protein,
decreased glucose, and increased polymorphonuclear white blood cells (WBCs). The most
likely diagnosis would be
(A) subarachnoid hemorrhage
(B) bacterial meningitis
(C) viral meningitis
(D) multiple sclerosis
(E) encephalitis - correct answer ✔✔(B) The cerebrospinal fluid (CSF) analysis in bacterial
meningitis includes a cloudy appearance
guide and exam preparation material
1. A 6-year-old boy is struck by a car while riding his bicycle. He is reported to be unconscious
for
2 minutes following the accident. He is conscious and alert upon arrival to the emergency
department, but within 45 minutes he begins to vomit and shortly thereafter he becomes
completely unresponsive. Which of the following most likely explains this child's injury?
(A) spinal cord transection
(B) chronic subdural hematoma
(C) acute epidural hematoma
(D) acute subarachnoid hemorrhage
(E) grade III concussion - correct answer ✔✔(C) This is the classic history of an epidural
hematoma. The typical presentation is that of a child
who sustains a hard blow to the head and experiences a brief loss of consciousness, followed by
a lucid interval, when the child is awake and alert. As the hematoma expands, the patient
experiences a headache followed by vomiting, lethargy, and hemiparesis and may progress to
coma if left untreated. This injury usually results from a temporal bone fracture with a
laceration
of the middle meningeal artery or vein and less often a tear in a dural venous sinus. Epidural
hematomas are treated with surgical evacuation of the clot and ligation of the bleeding vessel.
Spinal cord transection should not present initially as a loss of consciousness and will affect
distal motor and sensory function. Chronic subdural hematomas present more than 20 days
after
the trauma. Subarachnoid hemorrhage typically presents as a generalized headache without
associated trauma. A grade III concussion usually involves continued improvement after
consciousness is gained. The lucid period followed by worsening symptoms in this question is
,worrisome of more severe intracranial pathology. (Aminoff et al., 2005, p. 329)
2. A 75-year-old man is involved in a motor vehicle accident and strikes his forehead on the
windshield. He complains of neck pain and severe burning in his shoulders and arms. His
physical examination reveals weakness of his upper extremities. What type of spinal cord injury
does this patient have?
(A) anterior cord syndrome
(B) central cord syndrome
(C) Brown-Séquard syndrome
(D) complete cord transection
(E) cauda equina syndrome - correct answer ✔✔(B) The central cord syndrome involves loss of
motor function that is more severe in the upper
extremities than in the lower extremities, and is more severe in the hands. There is typically
hyperesthesia over the shoulders and arms. Anterior cord syndrome presents with paraplegia or
quadriplegia, loss of lateral spinothalamic function with preservation of posterior column
function. Brown-Séquard syndrome consists of weakness and loss of posterior column function
on one side of the body distal to the lesion with contralateral loss of lateral spinothalamic
function one to two levels below the lesion. Complete cord transection would affect motor and
sensory function distal to the lesion. Cauda equina syndrome typically presents as low back pain
with radiculopathy. (Hauser and Ropper, 2008, p. 2580)
3. A 41-year-old woman presents to the emergency department complaining of a sudden onset
of the
"worst headache of my life." A stat computed tomography (CT) scan of her head is found to be
normal. The next appropriate step in the diagnosis of this patient would be
(A) outpatient magnetic resonance imaging (MRI) of the brain
(B) complete blood cell count (CBC) with differential
,(C) injection of sumatriptan (Imitrex)
(D) lumbar puncture
(E) repeat CT scan in 48 hours - correct answer ✔✔(D) The hallmark of a subarachnoid
hemorrhage is the very sudden onset of a severe headache.
The headache is often described as the "worst headache of my life." A CT scan will detect a
subarachnoid hemorrhage in more than 95% of cases. When the history suggests subarachnoid
hemorrhage and the CT scan fails to detect bleeding, a lumbar puncture is mandatory. The
lumbar
puncture will yield bloody cerebrospinal fluid in subarachnoid hemorrhage. Outpatient MRI or
repeat CT scan in 48 hours would create a potentially harmful delay in diagnosis. CBC with
differential may be ordered but will not confirm the suspected diagnosis. Treatment with
Imitrex
is contraindicated in the presence of a potential cerebrovascular syndrome. (Hemphill and
Smith, 2008, p. 1728)
4. A 45-year-old woman with a known seizure disorder has been noncompliant with her anti-
convulsant medication due to side effects she has been experiencing. While in your office, she
starts convulsing at a frequency that does not allow consciousness. Which of the following is the
most appropriate initial drug treatment?
(A) lorazepam
(B) phenytoin
(C) phenobarbital
(D) valproic acid - correct answer ✔✔(A) Status epilepticus, defined as a continuous seizure or
repeated seizures in which interval
consciousness is not obtained, is a medical emergency. An intravenous infusion of a longer
acting
benzodiazepine, such as lorazepam, has been shown to be effective in terminating a seizure. If
the
seizures persist, then other potential agents to use after the initial lorazepam infusion include
, fosphenytoin (phenytoin) or valproic acid (phenobarbital). (Lowenstein, 2008, p. 2511)
5. While performing a routine history and physical examination on a 70-year-old man, you note
a
right carotid bruit. He denies any symptoms suggestive of a transient ischemic attack (TIA) or
cerebrovascular accident. A carotid Doppler ultrasound shows a 50% stenosis of the right
common carotid artery. The next most appropriate step would be
(A) stat carotid arteriogram
(B) initiate antiplatelet therapy with aspirin
(C) anticoagulate with warfarin
(D) intra-arterial tissue plasminogen activator (t-PA)
(E) carotid endarterectomy - correct answer ✔✔(B) The patient exhibits an asymptomatic
carotid bruit. The most appropriate step would be to initiate antiplatelet therapy with daily
aspirin. Arteriography would not be indicated for an
asymptomatic carotid bruit. Anticoagulation with warfarin (Coumadin) should be limited to
symptomatic bruits manifested as multiple TIAs. Carotid endarterectomy is reserved for carotid
stenosis that is greater than 70% in patients who have had recurrent TIAs on medical therapy.
(Aminoff et al., 2005, pp. 308-310)
6. A cerebrospinal fluid analysis reveals the following results: opalescent color, increased
protein,
decreased glucose, and increased polymorphonuclear white blood cells (WBCs). The most
likely diagnosis would be
(A) subarachnoid hemorrhage
(B) bacterial meningitis
(C) viral meningitis
(D) multiple sclerosis
(E) encephalitis - correct answer ✔✔(B) The cerebrospinal fluid (CSF) analysis in bacterial
meningitis includes a cloudy appearance
