ISBN: 9781483553610
TABLE OF CONTENTS
CHAPTER 1 - APPROACH
CHAPTER 2 - EPILEPSY
CHAPTER 3 - ANTI-EPILEPTIC DRUGS
CHAPTER 4 - ISCHEMIC STROKE
CHAPTER 5 - HEMORRHAGIC STROKE
CHAPTER 6 - HEADACHE
CHAPTER 7 - COMA / CONFUSION / SLEEP
CHAPTER 8 - EEG
CHAPTER 1 - APPROACH
1.
A 60-year-old patient presents with pain, numbness, and an impaired sensation over half of the face, along with ataxia, nystagmus, dysphagia, and hoarseness of the voice. His pain and thermal sensations on the opposite half of his body are impaired. Horner’s syndrome is present. The likely cause of the disease is thrombosis of which vessel? (AIIMS)
DISCUSSION:
This is a clinical presentation of lateral medullary syndrome. It presents with the following features on the side of the lesion: cerebellar ataxia, decreased skin sensation in the ipsilateral half of the face, Horner’s syndrome, vertigo, and weakness of the soft palate, larynx, and pharynx. On the opposite side of the body, there is numbness due to the involvement of the spinothalamic tract.
Lateral medullary (Wallenberg) syndrome is commonly seen due to thrombosis of the vertebral and posterior inferior cerebellar arteries.
ANSWER:
‘PICA (posterior inferior cerebellar artery).’
REFERENCES:
English JD, Johnston SC. Chapter 370. Cerebrovascular Diseases. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 18th edition; 2012.
Bates D. Chapter 24.9. Brainstem syndromes. In: Warrell DA, Cox TM, Firth JD, eds. Oxford Textbook of Medicine. 5th edition; 2010.
2.
A patient receiving therapy for pulmonary tuberculosis develops generalized tonic–clonic seizures. Which of the following antitubercular drugs is most likely to produce seizures? (AIIMS)
DISCUSSION:
Isoniazid (INH) is most often associated with nervous system side effects, most prominently peripheral neuropathy, psychosis, and seizures. Other side effects of antitubercular drugs involving the nervous system include optic neuropathy with ethambutol, ototoxicity, and neuromuscular blockade with aminoglycosides.
Rifampicin is mainly associated with hepatitis, while pyrazinamide is associated with joint pain and hepatitis.
ANSWER:
‘Isoniazid (INH).’
REFERENCES:
Kass JS1, Shandera WX. Nervous system effects of antituberculosis therapy. CNS Drugs. 2010 Aug;24(8):655-67.
Perkin G D. Chapter 24.5.1. Epilepsy in later childhood and adulthood. In: Warrell DA, Cox TM, Firth JD, eds. Oxford Textbook of Medicine. 5th edition; 2010.
3.
A 75-year-old woman was admitted to hospital after having suffered a cerebrovascular accident. On physical examination it was found that she was not responding to any visual, auditory, or tactile stimuli on the left side of her body. In addition, she had a deficit involving only the inferior portion of the left visual field in both eyes. A CT scan showed a non-hemorrhagic infarction in the right hemisphere. Which lobe of this patient’s brain had been principally affected by the stroke? (AIIMS)
DISCUSSION:
This patient had non-dominant parietal lobe involvement. Parietal lobe lesions are associated with contralateral hemisensory loss, astereognosis, agraphesthesia, and contralateral homonymous lower quadrantanopia. In addition, dominant parietal lobe lesions show a combination of finger agnosia, acalculia, and right-left confusion, while non-dominant parietal lobe lesions are associated with hemispatial neglect, spatial disorientation, constructional apraxia, and dressing apraxia.
ANSWER:
‘Parietal.’
REFERENCES:
Gijn van J. Chapter 24.10.1. Stroke: cerebrovascular disease. In: Warrell DA, Cox TM, Firth JD, eds. Oxford Textbook of Medicine. 5th edition; 2010.
English JD, Johnston SC. Chapter 370. Cerebrovascular Diseases. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 18th edition; 2012.
4.
A patient experiences loss of central vision in both eyes followed by a throbbing, unilateral headache. He is suffering from: (AIIMS)
DISCUSSION:
This is a typical presentation of classical migraine, which is characterized by an aura followed by a unilateral, throbbing headache, sometimes associated with nausea and vomiting.
Tension headache is featureless. Amaurosis fugax is not associated with headache. Delirium tremens is an acute confusional state precipitated by alcohol withdrawal.
ANSWER:
‘Classical migraine.’
REFERENCES:
Ivan Garza I et al. Chapter 69. Headache and Other Craniofacial Pain. In: Daroff RB, Fenichel GM, Jankovic J, Mazziotta JC. eds. Bradley’s Neurology in Clinical Practice, 6th edition; 2012.
Ropper AH, Samuels MA, Klein JP. Chapter 10. Headache and Other Craniofacial Pains. In: Ropper AH, Samuels MA, Klein JP. eds. Adams & Victor’s Principles of Neurology, 10th edition; 2014.
5.
A 65-year-old woman has had several episodes consisting of impaired vision in her right eye and numbness of the left side of her body, each lasting up to 4–5 minutes. Which of the following is the likely cause? (PGI)
DISCUSSION:
Involvement of the internal carotid artery is often suggested by the presence of hemispheric signs (like hemiparesis or hemianesthesia) on one side and recurrent transient monocular blindness or amaurosis fugax (due to ophthalmic artery involvement) on the other side.
Aneurysm rupture usually produces sudden onset, severe symptoms. Parasagittal meningioma and frontal lobe tumor both produce slowly progressive symptoms. Parasagittal meningioma often produces paraparesis, while frontal lobe tumor may produce contralateral hemiparesis.
ANSWER:
‘Internal carotid artery insufficiency.’
REFERENCES:
Gijn van J. Chapter 24.10.1. Stroke: cerebrovascular disease. In: Warrell DA, Cox TM, Firth JD, eds. Oxford Textbook of Medicine. 5th edition; 2010.
English JD, Johnston SC. Chapter 370. Cerebrovascular Diseases. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 18th edition; 2012.
6.
The combinations of disorientation, polyneuritis, loss of recent memory, and a tendency to confabulate are most likely due to: (AIIMS)
DISCUSSION:
An important effect of chronic alcohol misuse is Wernicke–Korsakoff syndrome. It results from damage to the mamillary bodies, dorsomedial nuclei of the thalamus, and adjacent areas of the periventricular grey matter caused by a deficiency of thiamin (vitamin B1). In addition, peripheral neuropathy is a common complication of alcoholism due to both nutritional deficiency and direct toxicity.
ANSWER:
‘Alcoholism.’
REFERENCES:
Thomson AD, Marshall EJ. The natural history and pathophysiology of Wernicke’s Encephalopathy and Korsakoff’s Psychosis. Alcohol Alcohol. Mar-Apr 2006;41(2):151-8.
So Y T, Simon R P. Chapter 57. Deficiency Diseases of the Nervous System. In: Daroff RB, Fenichel GM, Jankovic J, Mazziotta JC. eds. Bradley’s Neurology in Clinical Practice, 6th edition; 2012.
7.
A patient being evaluated for aphasia is unable to repeat sentences correctly or to name objects properly. However the patient’s speech is effortless and melodic. There are frequent errors in word choice and obvious difficulties in comprehension. The remainder of the patient’s neurologic examination is normal. Damage in which area of the brain would account for this type of aphasia? (AIIMS)
DISCUSSION:
This patient has impaired comprehension, repetition, and normal fluency. This is the typical presentation of Wernicke’s aphasia, and it often occurs because of occlusion of inferior division of left middle cerebral artery affecting Wernicke’s area. The middle cerebral artery divides into the superior division and the inferior division. Branches from the superior division supply the frontal and superior parietal cortex, and those of the inferior division supply the inferior parietal and temporal cortex.
ANSWER:
‘Posterior temporal and parietal lobes, dominant hemisphere.’
REFERENCES:
Gijn van J. Chapter 24.10.1. Stroke: cerebrovascular disease. In: Warrell DA, Cox TM, Firth JD, eds. Oxford Textbook of Medicine. 5th edition; 2010.
English JD, Johnston SC. Chapter 370. Cerebrovascular Diseases. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 18th edition; 2012.
8.
While pushing a car, a 25-year-old male develops a sudden headache, neck pain, and a positive Kernig’s sign. His BP is 150/100 mm Hg, and a fundus examination revealed a subhyaloid hemorrhage. The diagnosis is: (AIIMS)
DISCUSSION:
A spontaneous subarachnoid hemorrhage (SAH) usually occurs from a ruptured cerebral aneurysm. The symptoms include a severe headache with a rapid onset, vomiting, neck stiffness, confusion, or unconsciousness. The side of the aneurysm may be indicated by the unilateral preponderance of the headache or by a unilateral subhyaloid hemorrhage. The combination of SAH and subhyaloid hemorrhage is known as Terson syndrome.
Meningitis presents with fever and is subacute in onset. A cerebral hemorrhage is usually painless and without neck stiffness.
ANSWER:
‘Subarachnoid hemorrhage.’
REFERENCES:
Hemphill, III JC, Gress DR. Chapter 275. Neurologic Critical Care, Including Hypoxic-Ischemic Encephalopathy, and Subarachnoid Hemorrhage. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 18th edition; 2012.
Gijn van J. Chapter 24.10.1. Stroke: cerebrovascular disease. In: Warrell DA, Cox TM, Firth JD, eds. Oxford Textbook of Medicine. 5th edition; 2010.
9.
Which of the following conditions may lead to a syndrome characterized by delirium, ataxia, and extraocular movement abnormalities?
DISCUSSION:
Wernicke’s encephalopathy refers to the presence of neurological symptoms caused by thiamine (vitamin B1) deficiency. Classically it is characterized by the triad of ophthalmoplegia, ataxia, and confusion. Wernicke’s encephalopathy is treated with thiamine supplementation.
ANSWER:
‘Thiamine deficiency.’
REFERENCES:
Azim W, Walker R. Wernicke’s encephalopathy: a frequently missed problem. Hosp Med. Jun 2003;64(6):326-7.
Ropper AH, Samuels MA, Klein JP. Chapter 41. Diseases of the Nervous System Caused by Nutritional Deficiency. In: Ropper AH, Samuels MA, Klein JP. eds. Adams & Victor’s Principles of Neurology, 10th edition; 2014.
10.
A 66-year-old man sustains a cerebrovascular accident (CVA) after which he is alert but mute and unable to move his arms or legs. He has paresis of the palate, bilateral hyperreflexia, and Babinski signs. He responds correctly to verbal and written questions by blinking his eyelids. He has a normal EEG. All of the following statements except one are true of this condition. Which is the exception? (AIIMS)
DISCUSSION:
This is a typical presentation of locked-in syndrome. In these patients, the descending motor tract is affected, producing quadriparesis, hyperreflexia, and Babinski signs. In addition, bulbar weakness produces aphonia (where the patient is mute but alert) and paresis of the palate. Since the cortex is normal, EEG is also normal in these patients.
Aphasia is typically due to dominant hemispheric cortical involvement and is usually associated with hemiparesis.
ANSWER:
‘He has aphasia.’
REFERENCES:
Gijn van J. Chapter 24.10.1. Stroke: cerebrovascular disease. In: Warrell DA, Cox TM, Firth JD, eds. Oxford Textbook of Medicine. 5th edition; 2010.
English JD, Johnston SC. Chapter 370. Cerebrovascular Diseases. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 18th edition; 2012.
11.
A 15-year-old boy with epilepsy is being treated with a combination of valproate and phenytoin and has good control of his seizures. The levels of both drugs are in the therapeutic range. All of the following adverse effects except one can be attributed to valproate. Which is the exception? (AI)
DISCUSSION:
The neurological side effects of phenytoin are drowsiness, ataxia, confusion, blurred vision, and dizziness. Other common side effects include rashes, gum hypertrophy, thickening of the facial features, chorea, and lymphadenopathy.