Complete Answers Emergency Medicine Neurology Guide 2023 / 2024
(Brand New!!) TB Guide All Q&As Included!! A++
1) A woman presents with 30 minutes of double vision, vertigo, difficul- ty swallowing, and difficulty speaking. During her initial evaluation, these symptoms resolve and her neurologic exam returns to normal. Which of the following is the most appropriate diagnosis and the most likely affected artery?
Embolic ischemia - anterior cerebral artery Thrombotic stroke - left anterior descending artery Transient ischemic attack - middle cerebral artery Transient ischemic attack - vertebrobasilar arteries Answer ( D )
Explanation:
Transient ischemic attacks (TIAs) are characterized by an abrupt onset of focal neurologic symptoms lasting less than 24 hours and often lasting only five to 20 minutes. TIAs suggest impending thrombotic-ischemic stroke. Carotid pathology leads to TIAs demonstrated by hemiparesis, hemisensory, aphasia, confusion and transient monocular blindness. Vertebrobasilar insufficiency leads to TIAs marked by hemiplegia or quadriplegia, varying sensory changes, blindness, hemianopsia, diplopia, vertigo, dysarthria, dysphagia and facial, motor, and sensory change.Investigation includes Doppler ultrasonography of the carotids and vertebrobasilar system. Head CT scan will not show any acute changes. MRA angiography may also be indicated. Selected cases may require endarterectomy, angioplasty or lifelong anticoagulation.
Embolic ischemia typically produces symptoms that last longer than three hours and anterior cerebral artery (A) lesions do not produce vertigo and 1 / 4
diplopia.Thrombotic stroke (B) indicates infarct, which indicates permanent, not temporary or resolved, neurologic defect. Middle cerebral artery (C) lesions do not produce vertigo.
2) One Step Further
Question: What is the difference between plegia and paresis?
Answer: Plegia refers to paralysis (flaccid, no movement) while paresis refers to weakness (move- ment, but abnormal strength).
3) A 64-year-old man complains of pain and paresthesias in his right hand intermittently for several weeks.He works in a factory putting together elec- tronics.On exam, he has decreased sensation of his right 1st through 4th digits and an atrophied thenar eminence.What test in the ED will help diag- nose his condition?CT scan of the head Electromyelography (EMG) Percuss the right volar wrist Urine drug screen Answer ( C )
Explanation:
This patient has median mononeuropathy, also known as carpal tunnel syndrome, a compression neuropathy of the median nerve as it traverses under the flexor retinaculum at the wrist.The median nerve provides sensation primarily to the palmar aspect of the 1st, 2nd, 3rd, andradial side of the 4th.When it is compressed, the patient experiences pain, paresthesias, and numbness in that distribution.The Tinel's test is performed by lightly tapping the volar surface of the wrist over the median nerve.This should elicit a sensation of tingling or pins and needles in the distribution of the median nerve. Carpal tunnel syndrome is first treated with wrist splinting and initiation of a more ergonomic work environment. NSAIDs may also be helpful. If symptoms do not improve, the patient should be referred to a hand specialist who may elect 2 / 4
to perform a carpal tunnel release procedure CT scan of the head (A) would be useful if there issuspicion that this patients symptoms are from a central process such as an acute stroke. However, his numbness is in a peripheral nerve distribution and not dermatomal.An EMG (B) is used most commonly by neurologists to confirm damage to peripheral nerves. It may be used for carpal tunnel syndrome if the symptoms do not resolve with conservative management.A variety of heavy metals are associated with a periph- eral neuropathy (lead, mercury), but these require special serologic testing, not a urine drug screen (D).The patient is at risk for occupational exposures because he works in a factory; however, most heavy metal poisonings are associated with other symptoms.
4) One Step Further
Question: What is the Phalen maneuver?
Answer: The opposing dorsal sur- faces of the hands are pressed together with
the wrists flexed for 60 seconds. It is positive for median nerve problems if this reproduces or worsens symptoms.
5) A 42-year-old man displays personality changes and confusion for 2 days. He denies pain. Upon presentation, you discover a weak right leg, speech impairment and low-grade fever. Upper extremity and left leg strength, rectal sensation and muscle tone, reflex testing and four-extremity sensory exami- nation are normal. Nuchal rigidity, involuntary tremors, clonus and spasticity are absent. A brain MRI shows left temporal lobe edema. Cerebrospinal fluid analysis has an elevated number of red blood cells and the Gram stain is negative for bacteria. Which of the following is the most likely diagnosis?Encephalitis Meningitis Myelitis Sydenham's chorea 3 / 4
Answer ( A )
Explanation:
Encephalitis and meningitis manifest with similar symptoms, especially early in the infection. The classic meningitis triad is fever, headache and altered mental status, while altered mental status plus focal neurologic deficit is more descriptive of encephalitis. Herpes simplex encephalitis causes 10% of all diagnosed cases. More than half of these cases are fatal if untreated. HSV-1, commonly contracted in childhood (cold sores, fevers, and blisters), reactivates in adulthood to cause the majority of cases. Symptoms include up to 5 days of fever and headache, followed by behavior and personality changes, seizures, speech and memory deficits, hallucinations and altered consciousness. Frontal lobe pathology, leading to behavior and personality changes, and temporal lobe pathology, leading to mem- ory and speech problems, are most common. Herpes encephalitis is associated with elevated red blood cells on CSF analysis. In adults, T2-weighted MRI reveals hyperintensity corresponding to edematous changes in the temporal lobes, inferior frontal lobes, and insula, with a predilection for the medial temporal lobes. Foci of hemorrhage occasionally can be observed on MRI. Untreated HSV encephalitis is associated with high morbidity and mortality. Therefore, in suspected cases of encephalitis without an obvious source, empiric treatment with intravenous acyclovir is recommended. Young children and the immunocompromised are at greatest risk for HSV disease.
Meningitis (B) presents in a similar fashion to encephalitis early on. However, encephalitis is typically associated with behavioral and personality changes and neurologic deficits. Myelitis (C) (infection or inflammation of the spinal cord), typically presents with spinal pain, various sensory deficits, extremity weakness, reflex changes and bowel or bladder changes. Sydenham's chorea (D) occurs mainly in children with acute rheumatic fever or other Group A beta-hemolytic Streptococcus infection. It is characterized by face, hand and feet rapid jerking movements. Adult presentation is extremely rare.
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