Section 3 Flashcards
A 66-year-old female was admitted to the ICU after a motor vehicle accident causing a severe head injury. Brain death diagnosis was uncertain by physical examination, and the apnea test could not be performed due to CO2 retention. A transcranial Doppler (TCD) ultrasound on the middle cerebral arteries bilaterally did not detect any flow tracing. Which of the following is the next best step in managing this patient?
- Declare brain death
2. Order somatosensory evoked potentials - Repeat TCD after one day
- Continue medical management
- TCD can confirm brain death if it shows absent diastolic pulsations or small peaked systolic pulsations. The absence of flow tracing is inconclusive of brain death, as it may be due to an unsuitable window.
- Somatosensory evoked potentials may be ordered to determine brain death as TCD is inconclusive for this patient.
- The absence of flow tracing by TCD does not confirm brain death, as it may be due to an unsuitable window. Another ancillary test should be performed.
- Normal PCO2 is a prerequisite to performing the apnea test.
A 67-year-old female presents with a 1-hour history of right-sided weakness and aphasia. She has a history of atrial fibrillation and is taking aspirin only. The patient is alert and able to follow one-step commands. There is impairment of rightward gaze and left gaze deviation. Right face and arm flaccid paresis are present, but she can lift her right leg. There are decreased reflexes on the right side. What is the most commonly used study in a patient with this presentation?
- Brain MRI
2. Brain CT - CT angiography
- CT perfusion scanning
- The patient has had an acute cerebrovascular accident and is a candidate for tissue plasminogen activator (tPA).
- A noncontrast brain CT is the most commonly used study in the acute evaluation of patients with a suspected acute stroke.
- CT scanning is more commonly available, less expensive, and provides faster image acquisition than MRI. CT also can be used in patients who are unable to tolerate or who have contraindications to MRI.
- CT angiography, CT perfusion scanning, and MRI also can be used for emergent evaluation.
A SCUBA diver presents to the urgent care center with complaints of double vision after diving. This is his first dive since being newly certified four months ago. Upon visual examination, some bruising and swelling around his lower forehead and some eye redness is noted. He is also seen to have trouble moving one of his eyes laterally while complaining of diplopia. Which of the following is the next best step in the management of this patient?
- Place the patient on oxygen and transfer to a facility with a decompression chamber
- Reassure the patient that this is a mild injury and should resolve in a few weeks
3. Order an MRI or CT to evaluate the orbits of the eye - Discharge from the emergency department and refer to an ophthalmologist for a dilated fundoscopic examination
- The patient’s symptoms and exam are concerning for a subperiosteal hematoma involving the orbit. Imaging is indicated to confirm this diagnosis. MRI has the highest sensitivity, but CT may be initially used if MRI not available.
- The examiner must be able to distinguish signs of a more severe injury. The warning signs would include severe eye pain, diplopia, or loss of visual acuity.
- Oxygen should only be administered to patients with a suspected decompression injury. A mask squeeze is considered a traumatic injury as the result of “suction” of such force to disrupt cell membranes and rupture small vessels.
- This patient will need evaluation by an ophthalmologist and possibly a fundoscopic examination. However, this condition is likely an emergency and may require surgical intervention or drainage.
Which of the pathophysiological mechanisms of Dejerine-Roussy syndrome is also proposed to be seen in other neurological processing such as memory?
- Central disinhibition
2. Central sensitization - Central imbalance
- The grill illusion theory
- Dejerine-Roussy syndrome is a type of central post-stroke pain syndrome caused by damage to the thalamus.
- The synaptic efficacy is increased due to repetitive stimulation and will cause a response to be evoked at suboptimal levels of stimuli. This mechanism also is seen in the generation of memory.
- Central imbalance is the cause of a spectrum of pain quality perceived by patients with Dejeine-Roussy syndrome.
- The grill illusion theory of pathophysiology is not seen in the generation of memory.
What occurs with the induction of anesthesia using only nitrous oxide?
1. Increased intracranial pressure
2. Decreased cerebral blood flow
3. Decreased intracranial pressure
4. Cerebrovascular dilatation
- Induction with nitrous oxide is associated with elevated cerebral blood flow and increased intracranial pressure.
- Nitrous oxide induces intoxication, euphoria, dysphoria, spatial disorientation, temporal disorientation, and reduced pain sensitivity. Some users will have uncontrolled vocalizations and muscle spasms.
- If pure nitrous oxide is inhaled without oxygen, this can cause oxygen deprivation resulting in hypotension, syncope, and myocardial infarction.
- Long-term exposure may cause vitamin B12 deficiency. Symptoms of vitamin B12 deficiency include sensory neuropathy, myelopathy, and encephalopathy. Symptoms are treated with high doses of vitamin B12, but recovery can be incomplete.
A 65-year-old male patient was brought to the emergency department following the sudden onset of headache and right sided weakness. On examination, he also has ptosis of his left eye with his eye laterally deviated. An urgent MRI brain, including diffusion-weighted images (DWI) and apparent diffusion coefficient (ADC), is planned. Based on this clinical scenario, the site of stroke is best located at which of the following territory?
- Oculomotor nucleus region
- Rostral oculomotor fascicular region
3. Caudal oculomotor fascicular region - Cavernous sinus
- The patient has involvement of the corticospinal tract, medial rectus, and the levator palpebrae superioris.
- The fascicular arrangement of the midbrain oculomotor nerve is speculated to be a pupillary component, extraocular movement, and eyelid elevation in that rostrocaudal order.
- So small vascular insult involving the caudal region of the oculomotor fascicles can present with the above clinical patterns.
- Oculomotor nuclear lesion leads to bilateral ptosis. Lesions in the cavernous sinus lead to ophthalmoplegia with the involvement of third, fourth and sixth nerves as well.
A 58-year-old woman originally presented six months ago with complaints of pulsatile blurring of her vision, a subjective pulsatile orbital bruit, and headache. She was found to have a low-flow indirect carotid-cavernous fistula. Her inferior petrosal sinus was in discontinuity with her jugular system, so transfacial catheterization of the superior ophthalmic vein was attempted. After two unsuccessful attempts, she is scheduled for direct cannulation and told to perform carotid compression in the interim. In the preoperative holding area, she reports that she has been symptom-free for over two weeks. Which of the following is the next best step in management?
- Attempt transvenous embolization via transfacial catheterization again. Since she is improving, the likelihood of success is now higher
- Continue with the scheduled procedure to provide definitive treatment and closure of her fistula
3. Cancel the procedure and suggest careful surveillance since her fistula may have resolved - Cancel the operation and schedule her for stereotactic radiosurgery
- Anywhere from 10% to 60% of carotid cavernous fistulas will spontaneously resolve completely. Low-flow indirect fistulas may be more likely to resolve without intervention. In these settings, intervention is unnecessary.
- It is important to perform a history and physical on each patient with a carotid cavernous patient before an operation is performed. Given the high rate of spontaneous resolution, a procedure may be unnecessary.
- The role of compression therapy in the management of carotid cavernous fistulas remains unclear. Up to 30% of persistent low- flow, indirect lesions will resolve with conservative management; however, the impact of compression therapy is not known.
- Stereotactic radiosurgery is a noninvasive treatment for carotid cavernous fistulas. However, this often involves a latent period and has lower efficacy compared to endovascular intervention. In this case, the resolution of symptoms supports surveillance, not a transition to a different treatment modality.
A 67-year-old male is discussed in the head and neck interprofessional meeting. He has presented with a biopsy- proven squamous cell carcinoma (SCC) on the apex of his scalp measuring 5 cm in diameter. It had been growing over the last 6 month prior to him seeking medical help. CT imaging shows a deep lesion but that the underlying skull appears unaffected. What is the best course of action from the options stated below?
- Excise the lesion with appropriate margins and close with a rotational flap
- Excise the lesion with appropriate margins and examine the bone below; if the bone is uninvolved close with a full-thickness skin graft
3. Excise the lesion with appropriate margins and examine the bone below; if the bone is uninvolved close with a split-thickness skin graft - Excise the lesion with appropriate margins and close with a free flap
- Risk factors for SCC of the scalp include long term sun exposure, having fair skin (low Fitzpatrick skin types), chronic lesions, and immunosuppressed patients.
- The depth of invasion is an important prognostic factor for survival, with dural and brain parenchyma involvement being considered inoperable.
- Calvarial involvement requires bone to be drilled or removed. Often with large SCC scalp lesions, sentinel lymph node biopsying is done. This will help to decide on adjuvant therapy.
- Split-thickness skin grafting (STSG) would be ideal with the large defect caused here. The take rate is higher in STSG due to the graft’s lower metabolic requirements. As this defect is down near to bone the vascular bed left behind the following excision will be poor, making a full-thickness skin graft more likely to fail. A dermatome is used to take donor skin from the thigh. The patients often require postoperative radiotherapy, but this requires further discussion at the interprofessional team meeting.
A 65-year-old male sustained a fracture of the atlas during a motor vehicle accident. The patient is stabilized in the emergency department and is scheduled for a posterior instrumented fusion between the C1 and C2 vertebrae. Which of the following will decrease the risk of vertebral artery injury?
- Transarticular screw fixation at the level of C1-C2
- Exposing 2.0 centimeters of the posterior arch of C1 for better visualization
3. Dissecting less than 1.5 centimeters of the posterior arch of the atlas - Dissecting less than 3.0 centimeters of the posterior arch of the atlas
- The vertebral artery is located approximately 1.5 centimeters from the posterior arch of the atlas. Transarticular screw placement at the level of C1-C2 carries a higher risk of vertebral artery injury than a fixation with lateral mass screws to C1 and pedicle screws to C2.
- While exposing the posterior arch of C1, the surgeon should avoid dissecting past 1.5 centimeters from the midline to avoid injury to the vertebral arteries.
- The vertebral arteries travel from the lateral aspect of the vertebrae to the medial vertebrae, over the superior aspect of the posterior arch of C1. Exposing less than 1.5 centimeters while dissecting will prevent the surgeon from damaging the vertebral arteries.
- During placement of C1 lateral mass screws, the screw should be angled 10-15 degrees medially to avoid the vertebral artery, which courses laterally.
A 65-year-old male with diabetes mellitus, chronic kidney disease, and hypertension was recently hospitalized with bacteremia stemming from a urinary tract infection. His hospital course was complicated with persistent low back pain led to an MRI being performed. Which of the following risk factors is this patient at greatest risk?
- Age of this patient
2. History of diabetes - History of chronic kidney disease
- Hypertension
- Diabetes is the greatest risk factor for discitis in this patient.
- Discitis is more common in the pediatric population than in adults.
- Although chronic kidney disease, cirrhosis, and intravenous drug abuse are risk factors, diabetes is the most common.
- Discitis is more common in males than in females.
A 35-year-old woman with no significant past medical history presents for the evaluation of a pituitary mass found incidentally on MRI brain imaging done after a recent motor vehicle collision. The pituitary mass is described as 1.1 x 0.9 x 0.9 cm, homogeneous enlargement of the pituitary without compression of the optic chiasm. The patient has no complaints. Medications include calcium and vitamin D as she is breastfeeding. She delivered a healthy baby three months ago. Lab work reveals normal TSH of 2.2 microU/ml, free T4 0.9 ng/dl, and prolactin 89 ng/ml. Other pituitary hormones are within normal limits. What is the most likely diagnosis?
- Prolactinoma
- Nonfunctioning macroadenoma
3. Pituitary hyperplasia - TSH-secreting adenoma
- Pituitary hyperplasia on MRI brain appears as a homogeneous enlargement of the gland.
- Pituitary hyperplasia can be a normal response to physiological stimulation during adolescence, pregnancy, and lactation or as a pathological condition.
- During pregnancy and lactation, striking hypertrophy of the pituitary can occur. The gland commonly reaches a height of 10 mm by the third trimester and obtains maximal height of 12 mm in the first postpartum week.
- Pregnancy and lactation cause a physiologic elevation in prolactin. In prolactinoma, prolactin levels are usually more than 200 ng/ml.
A 61-year-old male with a past medical history of type 2 diabetes mellitus for the past 20 years has been having burning pain in his right calf and lateral foot for the past few months. On examination, the posterolateral aspect of the leg is tender to palpation. After nerve conduction studies are performed, it is determined that the cutaneous nerve formed by branches of both the tibial nerve and common peroneal nerve has been impinged. Where should the surgeon incise to decompress the nerve?
- Between the dorsalis pedis artery and medial malleolus 2. Between the medial malleolus and the Achilles tendon 3. The plantar fascia
4. The superficial sural aponeurosis
- Entrapment of the sural nerve is most often caused by fascial thickening at the site where the nerve becomes superficial to the gastrocnemius, called the superficial sural aponeurosis.
- The sural nerve supplies sensation to the medial and lateral aspects of the foot on either side of the heel.
- The sural nerve distally runs in between the lateral malleolus and Achilles tendon, 2.5 cm posterior to the lateral malleolus.
- In patients with peripheral neuropathy that has no clear underlying cause, a sural nerve biopsy may be helpful in discovering the histopathological etiology.
A 37-year-old female patient with multiple sclerosis had an initial presentation 5 years ago with optic neuritis that completely resolved without treatment. Three years ago, she had sensory and motor involvement of the upper extremities and was treated with corticosteroids. Two years ago, she was treated with interferon beta-1A. Three days ago, she developed the decreased sensation of the left lower trunk without tingling, pain, gait problems, bowel or bladder problems, or systemic symptoms. Exam shows normal visual fields with a right afferent pupillary defect. There is decreased sensation to light touch over the right trunk. Rapid alternating movements, finger tapping, heel tapping to the shin, and finger to the nose are all-normal. What is the most appropriate management for this patient at this time?
1. Corticosteroids
2. Fingolimod
3. Interferon beta-1B
4. Azathioprine
- The patient has a flare-up of multiple sclerosis (MS) and would be most effectively treated with corticosteroids.
- The long-term outcome may not be affected, but this treatment will usually reduce the severity and length of the flare-up.
- The other options are used to prevent MS exacerbations but are not used for acute flare-ups.
- Another option for acute flare is plasmapheresis. It is an option when corticosteroids are ineffective or contraindicated.
A 50-year-old man suddenly fell on the roadside while walking. He does not obey when told to open his eyes and say his name. When pain is applied to his trapezius, he tries to move away. What is his most likely AVPU (alert, verbal, pain, unresponsive) score?
- A
- V
3. P - U
- The AVPU scoring scale is a simplification of the Glasgow coma scale.
- The score is defined as A= alert, V= response to verbal stimuli, P= response to painful stimuli, U= unresponsive.
- Since the patient is responding to pain only, he should be given a score “P.”
- Alert corresponds to GCS of 15; voice responsive corresponds to GCS of 12, pain responsive corresponds to GCS of 8, and unresponsive corresponds to GCS of 3.
A 27-year-old female with a history of otitis media presents with white otorrhea in the right external auditory canal and diminished hearing. An otologic exam reveals white debris in the posterosuperior tympanic membrane quadrant. A CT of the temporal bones was performed. Which of the following findings necessitates MR imaging in this case?
- Soft tissue mass
- Ossicular erosion
3. Breached tegmen tympani - CNVII canal dehiscence
- Cholesteatoma is a soft tissue mass composed of proliferating stratified squamous epithelium and anucleated keratin debris, often caused by chronic middle ear inflammation. While the lesions are benign, they can erode into the CNS and cause severe complications.
- Cholesteatoma appears pearly on gross examination. It may present with aural discharge, conductive hearing loss, otalgia, and Tullio phenomenon.
- CT demonstrates soft tissue extending from the right external auditory canalto the right epitympanum with blunting of the scutum, widening of Prussak space, and mild ossociular erosion. There is also thinning of the tegmen tympani, which may require MRI to exclude intracranial complications such as venous sinus thrombosis, meningitis, and epidural abscess.
- Treatment may involve tympanomastoidectomy with or without ossicular reconstruction. The two major types of mastoidectomies performed are canal wall up (CWU) and canal wall down (CWD), the latter of which results in lower rates of recurrence.
A 25-year-old male was recently diagnosed with cluster headache. He is admitted with a persistent headache and excessive lacrimation that is refractory to pharmacologic intervention. Vidian neurectomy was performed to treat this complication. Which of the following is the most susceptible structure to be injured during this procedure?
1. Greater petrosal nerve
2. Geniculate ganglion
3. Carotid sinus
4. Superior salivatory nucleus
- The greater petrosal nerve fuses with the deep petrosal nerve in the Vidian canal. The Vidian canal is formed in the bony process of the foramen lacerum.
- The greater petrosal nerve, also known as the large superficial petrosal nerve, is a nerve in the skull that branches from the facial nerve (CN VII).
- The greater petrosal nerve forms part of a chain of nerves that innervate the lacrimal gland. The fibers have synapses in the pterygopalatine ganglion (also known as the sphenopalatine ganglion). Geniculate ganglion gives rise to the greater petrosal nerve, which passes to the foramen lacerum.
- The greater petrosal nerve carries parasympathetic preganglionic fibers from the facial nerve to the lacrimal gland. The superior salivatory nucleus, located in the pons, gives rise to the pre-ganglionic para-sympathetic fibers.
A 40-year-old male presents to the clinic with paresthesia to the dorsal surface of his hand. He works as a carpenter and while he is at work he is continuously using a screwdriver every day. His symptoms are caused by compression of the terminal branches of the nerve originating from the posterior cord of the brachial plexus. Which two tendons are compressing this nerve?
1. Brachioradialis and extensor carpi radialis longus
2. Brachioradialis and flexor carpi radialis
3. Brachioradialis and abductor pollicis longus
4. Brachioradialis and extensor pollicis brevis
- Wartenberg syndrome (cheiralgia paresthetica) results from the compression of the superficial branch of the radial nerve.
- At approximately 9 cm proximal to the styloid process, the superficial radial nerve passes through the deep fascia of the forearm. It emerges between the brachioradialis and extensor carpi radialis longus to eventually become subcutaneous.
- Pronation crosses the extensor carpi radial longus beneath the brachioradialis, which can lead to compression of the nerve. Repetitive action such as supination and pronation or hyperpronation can lead to Wartenberg neuritis.
- The radial nerve originates from the posterior cord of the brachial plexus
A 34-year-old woman presents to the emergency department after a motor vehicle collision. She was a restrained passenger and now complains of severe abdominal pain as well as pain in her back. She has fully intact sensation in bilateral lower extremities and demonstrates 5/5 strength in ankle plantarflexion and dorsiflexion. Straight leg raise is limited by back pain. The rectal tone is good. A CT scan is obtained, and a midsagittal slice is shown below. What is the mode of failure of the posterior spinal column of this patient?
- Compression
- Shear
3. Tension - Torsion
- A chance fracture of the spine is a flexion-distraction injury of the spine where the anterior spinal column fails in compression, and the middle and posterior spinal columns fail under tension.
- The center of rotation for a bony chance fracture is through the abdominal viscera.
- There is a high association with gastrointestinal injuries with chance fractures (50%).
- Disruption of the posterior spinal ligamentous elements necessitates surgical fixation, but bony chance fractures are stable injuries. The abdominal injuries may necessitate further workup.
A 4-year-old boy is brought to the emergency department after an accidental fall from a bike. The child is active, playful, and tolerating oral feeds normally. A reconstructed image from the patient’s CT head is shown in the figure. Which of the following is the next best step in the management of this patient?
- Cranioplasty
- Bone cement repair
- Venogram study
4. Reassurance
- The reconstructed 3D CT image is characteristic of an unossified lambdoid suture in the child.
- It is a normal anatomical variation and does not require any surgical management.
- The lambdoid suture may remain patent until the child reaches adulthood.
- A venogram is justified in cases with compound depressed fractures overlying the transverse sinus. Mesh repair is justified in significant bony defects following compound comminuted depressed fractures.
An adolescent patient presents to the office for initial evaluation after the school nurse noted a thoracolumbar prominence on routine scoliosis screening. Diagnostic imaging reveals findings compatible with Scheuermann disease. Which of the following radiographic findings is most characteristic of this diagnosis?
- Compression fracture deformity of the thoracic vertebrae
2. Vertebral body wedging in at least three adjacent levels (greater than 5 degrees) - Disk space narrowing with herniations at multiple adjacent levels
- Endplate sclerosis and osteophytic lipping at multiple adjacent levels
- Kyphosis most commonly occurs in the thoracic spine.
- Radiographic imaging may also note endplate narrowing and Schmorl’s nodes.
- Scheuermann disease is defined as vertebral body wedging of greater than 5 degrees in at least three contiguous vertebrae.
- Correction of kyphosis by hyperextension of the vertebrae rules out Scheuermann disease.
A 70-year-old female came to the emergency department with right-sided weakness and Broca aphasia. Her last known normal is 16 hours ago. NIH stroke scale is 16. Based on the recent advancements in stroke care, which of the following perfusion CT prompt one to take for mechanical thrombectomy?
- Cerebral blood volume and cerebral blood flow are decreased 2. Cerebral blood flow less than 10 ml/100 g/min
- Decreased cerebral blood volume
4. Increased mean transit time and decreased cerebral blood flow
- In an infarcted area of brain tissue, cerebral blood volume and cerebral blood flow are decreased.
- Cerebral blood flow less than 10 ml/100g/min is an infarcted tissue already.
- Decreased cerebral blood volume is used for identifying core
- The penumbra is the area of ischemia surrounding the infarct site with Increased mean transit time, cerebral blood volume increased, and decreased cerebral blood flow
A 38-year-old man presents to the emergency department after a motor vehicle collision. He was a restrained passenger and now complains of severe abdominal pain as well as pain in his back. His rectal tone is good and displays no bowel or bladder incontinence. He has a fully intact sensation in the bilateral lower extremities. Straight leg raise is limited by back pain. A CT scan is obtained, and a midsagittal slice is shown below. What is the mode of failure of the anterior spinal column?
1. Compression
2. Shear
3. Tension
4. Torsion
- A Chance fracture of the spine is a flexion-distraction type injury centered at the abdominal viscera.
- A Chance fracture of the spine is a flexion-distraction injury of the spine where the anterior spinal column fails in compression, and the middle and posterior spinal columns fail under tension.
- There is a very high association of gastrointestinal injuries associated with Chance fractures.
- Bony chance fractures, as seen above, are stable injuries and can be treated non-operatively. However, ligamentous chance fractures require surgical fusion.
A 34-year-old woman is brought to the hospital by ambulance after sustaining a head injury resulting in loss of consciousness in a car accident. She regained consciousness and recalls events leading up to the accident but is confused about what happened after. She knows where she is, what year it is, and recalls her name and date of birth without difficulty. The patient reports headache 10/10 with mild nausea but no vomiting. She denies any focal weakness in upper or lower extremities, tingling, numbness. Her physical exam shows a 6 cm swelling on the occipital scalp, tender to touch with bruising and intact skin. Eyes are equal and reactive to light bilaterally. The uvula is midline, CN II-XII are intact, with motor and strength 5/5 in upper and lower extremities. Clinically the patient seems to have a concussion with a contusion at the site of impact. Which of the following is the next best step in the management of this patient?
- CT maxillofacial
- CT head and cervical spine with contrast
3. CT head and cervical spine without contrast - MRI head
- CT head and cervical spine can rule out serious traumatic injury.
- Simple concussions do not typically show up on the CT scan in the first 24-48 hours. Whiplash injury of the cervical spine can result in a muscle spasm in which the normal curvature, lordosis, of the cervical spine is straightened.
- CT scan will rule out more serious injuries such as a skull fracture, brain hemorrhage, or subdural hematoma, epidural hematoma.
- CT maxillofacial does not provide full imaging of the brain and is useful for facial fractures. CT head without contrast should be performed to rule out more serious, life-threatening traumatic injuries. CT with IV contrast is not essential but should be used in cases where there is a high suspicion of intracranial/intraparenchymal hemorrhages.
A highly obese 53-year-old female presents to the clinician with a history of right-sided facial (Bell’s) palsy for almost a month. She also complains of difficulty in chewing and swallowing food. Her history is significant for uncontrolled diabetes and hypertension. On examination, her vitals include a blood pressure of 174/100 mmHg, a pulse of 85 beats per minute, respiration of 16 breaths per minute, and a temperature of 98 degrees Fahrenheit. Her random blood glucose was 376 mg/dl. On further examination, the clinician noticed that the problem in swallowing is because of the paralysis of one of the muscles of the suprahyoid region on the right side which is affected due to a lesion in the facial nerve that is supplying it. What is this muscle that is most likely paralyzed?
- Mylohyoid muscle
- Geniohyoid muscle
- Omohyoid muscle
4. Stylohyoid muscle
- The suprahyoid muscles include digastric, stylohyoid, geniohyoid, and mylohyoid.
- The stylohyoid muscle and the posterior belly of the digastric muscle are innervated by the facial nerve (VII cranial nerve).
- The stylohyoid muscle helps in the elevation of the tongue and elongates the floor of the mouth and helps in deglutition.
- The Geniohyoid muscle is supplied by the first cervical nerve via the hypoglossal nerve. The mylohyoid muscle and anterior belly of the digastric muscle are innervated by the mandibular branch of the trigeminal nerve.
A 35-year-old woman presents to the neurology clinic following persistent headaches and progressive diminution of her vision. Her fundoscopic exam revealed bilateral early optic atrophy. The image of her MRI brain is shown. The symptoms in the patient were refractory to medical management. Which of the following modality is most effective in the management of the patient?
- Optic nerve fenestration
- Bariatric surgery
- Ventriculoperitoneal shunt
4. Veno-sinus stenting
- The patient has clinical and radiological features (empty sella syndrome) consistent with idiopathic intracranial hypertension (IIH).
- Venous sinus narrowing and stenosis are now considered to play an important and curable role in the pathogenesis of IIH.
- Veno-sinus stenting has shown to have the best clinical and visual benefits among various forms of operative interventions considered for IIH.
- The optic nerve fenestration has benefits in managing visual diminution. Bariatric surgery is considered among patients with a normal venogram study.
A 54-year-old female presents with a complaint of slurred speech for the past two days. She also noticed poor coordination in her left leg and trouble gripping her left hand when she went home last night. In addition, she was drooling out the left side of her mouth. At the time of assessment, she reports having the worst headache ever. She notes that the pain is generalized but states that it is 10/10 in severity. She has a history of mitral valve replacement and is anticoagulated with warfarin. CT head without contrast is shown. She was given prothrombotic complex concentrate (PCC) after having supra-therapeutic INR > 5 on warfarin which later came down to 2.0. What is the next best step in the management of this patient?
- Monitor the progression of hematoma expansion and hold reversal agents
2. Give a dose of PCC or Fresh Frozen Plasma with Vitamin K to reduce INR 1.3 - Give a dose of a reversal and check the INR
- Give vitamin K only and monitor the progression of hematoma with daily CT head for the next 72 hours
- Monitoring the hematoma expansion is the next step after achieving the target INR with a reversal agent.
- The goal of reversal agents is to achieve a target INR 1.3 to avoid hematoma expansion. If the repeat INR after 6 hours of a previous reversal agent is still >1.3, the repeat dose of either PCC or FFP is required.
- INR should be checked every four to six hours for the first 24 hours and then checked daily for a few days.
- Vitamin K is always given with FFP, PCC, or Factor VII for warfarin-associated intracranial hemorrhage. Vitamin K has a delayed onset of action compared to PCC and FFP but achieves a steady decrease in INR over the next 12 to 24 hours compared to PCC or FFP alone.
A 30-year-old man presents with head trauma after an assault. On physical exam, there is bruising over the right mastoid process. A CT of the temporal bones is performed. Which of the following structures is most likely injured?
- Facial nerve
- Lateral semicircular canal
- Internal carotid artery
4. Incudomalleolar joint
- Temporal bone fractures typically result from high-impact blunt head trauma. The temporal bone has complex anatomy including four geographic parts (squamous, mastoid, petrous, tympanic) and numerous named foramen/canals (foramen lacerum, carotid canal, internal acoustic meatus, jugular foramen).
- Common associated injuries include hearing loss, facial palsy, extra-axial hemorrhage, and cerebral contusion.
- In this case, CT demonstrates a longitudinal fracture of the right temporal bone with ossicular chain disruption. Temporal bone fractures that violate the otic capsule have a much higher association with CSF leak, sensorineural hearing loss (SNHL), and certain intracranial pathology.
- Treatment and management of associated life-threatening, intracranial pathology should be the primary focus. Formal audiological evaluation is deferred several weeks post-injury to ensure edema and hemotympanum have completely resolved.
A patient presents to the clinic with complain of back pain. On history, the patient reveals that he experiences shooting pain from his buttocks to the leg since he fell from stairs 2 weeks ago. A complete neurological exam was conducted by the clinician and MRI of the lumbosacral region was advised. MRI shows the impingement of the anterior nerve root at L5. What would be an indication for surgical repair of the problem?
- A weakness of the ipsilateral lower extremity and shooting leg pain.
- Immediate surgical intervention is required, no matter if the patient is symptomatic.
3. Persistent, intractable pain following exhaustion of all possible nonoperative treatment options (physical therapy, rest, NSAIDs). - Whenever the patient electively chooses to have surgery performed.
- The most common indication for surgical intervention is persistent, intractable pain following exhaustion of all possible nonoperative treatment options (physical therapy, rest, NSAIDs) for a minimum of a dedicated 6 week period.
- Even in the setting of acute injuries with MRI evidence of a lumbar disc herniation and correlating clinical symptoms in the motor/sensory distribution of the specific nerve root(s) involved, nonoperative management remains the mainstay of initial treatment.
- Greater than 95% of lumbar disc herniations involves the L4/L5 and/or L5/S1 disc spaces, with patients typically presenting with low back pain with sharp, stabbing pain often traceable form the lower lumbar region to the lower leg and foot.
- Lower extremity radiculopathy, often ambiguously ill-defined even by healthcare providers and physicians as “Sciatica,” is often attributable to nerve root(s) compression and impingement at one or multiple nerve roots in the lumbosacral plexus. These roots ultimately contribute innervation (motor/sensory) peripherally as the sciatic nerve, manifests as shooting, stabbing, and/or burning pain radiating from the back to the ipsilateral or contralateral lower extremity.
An 80-year-old man with a history of coronary artery disease presents with one day of confusion and aphasia. An MRI of the brain is performed. Which of the following is the most likely diagnosis?
1. Arterial ischemia
2. Deep venous thrombosis
3. Wernicke encephalopathy
4. Acute disseminated encephalomyelitis
- Thalamic infarcts are often the result of vertebrobasilar disease. Rarely, occlusion of the artery of Percheron (common vascular trunk that arises from one P1 segment) can be causative.
- Presentation depends on the region affected and may include cognitive/behavioral disturbances, aphasia, hemineglect, ophthalmoplegia, and sensorimotor deficits.
- In this case, DWI demonstrates small areas of restricted diffusion in bilateral central thalami, which do not appear engorged.
- Thalamic infarcts are often managed medically. Outcome is usually positive with return to baseline neurological function.
A 40-year-old man presents with a nine-month history of lower back pain. The pain is constant and affecting his ability to exercise and is aggravated when he sits for long periods, with coughing and sneezing. It is located in the midline at approximately the L5 level. His past medical history includes radicular pain, which has decreased. He has done three months of a core-based physical therapy program without much improvement, and three epidural steroid injections that yielded only three weeks of relief each time. An MRI demonstrates L4-5 moderate disc degeneration with a posterior high-intensity zone and bulge. A procedure to determine if the disc is the origin of the patient’s chronic spine pain prior to an L4-5 total disc arthroplasty is performed (see below). What position should be patient be in for this procedure?
- Supine
2. Prone - Sitting
- Standing
- A provocative discography (PD) is an invasive diagnostic spine procedure. Contrast is administered into the nucleus pulposus of an intervertebral disc. The test is based on the premise that discs can be a source of spine pain, and symptomatic, internally disrupted disc causes pain when it is mechanically loaded; therefore, it should be similarly painful when pressurized with injected contrast.
- PD should only be employed when there is a moderate to high pretest probability that the spine pain is suspected to be of discogenic origin. This is based on history and advanced imaging findings. The information obtained from the test will be used to rule out or plan subsequent treatment decisions such as therapeutic intradiscal procedures (e.g., intradiscal electrothermal therapy, annuloplasty, regenerative medicine) or surgery (e.g., disc arthroplasty, interbody fusion).
- PD is performed in a procedural suite with x-ray fluoroscopy. The patient is positioned prone, except in the case of cervical discography where they are supine.
- Several decades have passed since the advent of PD. Arguably it is the best method to determine with reasonable certainty the presence or absence of discogenic spine pain.
A 6-year-old male with a long history of trouble with coordination presents to the office. Based on the results of the brain MRI, the pediatrician explains that the patient presents a malformation that is associated with vermian and cerebellar hypoplasia. Which of the following complications is most associated with this malformation?
1. Hydrocephalus
2. Facial malformations
3. Seizures
4. Gastrointestinal bleeding
- Dandy-Walker is comprised of hypoplasia of the cerebellar vermis, dilation of the 4th ventricle, and elevation of the cerebellar tentorium.
- 70-90% of patients with Dandy-Walker malformation present hydrocephalus.
- Dandy-Walker is also associated with malformations of the face, limbs, heart
- DWM may be isolated or associated with chromosomal abnormalities, Mendelian disorders, syndromic malformations, congenital infections, and various other comorbidities.
A 42-year-old woman presents to the emergency department after a motor vehicle collision complaining of back pain. She was a restrained passenger. She has fully intact sensation in bilateral lower extremities and demonstrates 5/5 strength in ankle plantarflexion and dorsiflexion. Straight leg raise is limited by back pain. The rectal tone is good. A CT scan is obtained, and a midsagittal slice is shown below. What are associated injuries most concerning for this patient?
1. Abdominal visceral injuries
2. Chest wall injuries
3. Closed head injuries
4. Long-bone fractures
- A Chance fracture of the spine is a flexion-distraction injury of the spine with the center of rotation at the abdominal viscera where the anterior spinal column fails in compression, and the middle and posterior spinal columns fail under tension.
- Chance fractures have a very high (50%) association with gastrointestinal injuries due to the center of rotation being at the abdominal viscera.
- A thorough gastrointestinal examination is warranted in all cases of bony chance fractures, and patients with any signs of abdominal trauma due to seatbelt injuries.
- Bony chance fractures, as seen in this image, can be managed non-operatively, whereas ligamentous chance fractures necessitate surgical stabilization.
A 55-year-old male was brought into the emergency room with right hemiplegia and loss of consciousness. GCS was E1M5V1. The pupil on the left side was 3 mm and nonreactive. CT brain showed large hyperdensity in the left basal ganglia and ventricles, with mass effect and midline shift of 8mm. What will be the ideal treatment?
- Intubation, hyperventilation with sedation, and hemostatic therapy alone
- Intubation, hyperventilation with sedation, hemostatic therapy, and mannitol
3. Intubation with sedation, hyperventilation, mannitol, and decompressive craniectomy - Expectant line of management
- Since the patient has large ICH with edema, mass effect, and midline shift, he requires maximum antiedema measures.
- Decompressive craniectomy, evacuation of hematoma, and expansive duraplasty improve outcomes in patients with large hematoma and coma with GCS below 8.
- Intubation should be with sedation; otherwise, intracranial pressure will rise further.
- Hyperventilation should be to maintain a pCO2 of 28 to 32 mmHg.
A 32-year-old woman presents after a fall on an icy sidewalk where she hit her head and lost consciousness for several minutes. Her vital signs show oxygen saturation of 98% on room air, respiratory rate of 20 per minute, heart rate of 55 beats per minute, blood pressure of 140/90 mmHg, and temperature of 36.7 C (98 F). On examination, she is awake and alert and complains of a severe headache. There are no cranial nerve, motor, or sensory deficits. Babinski sign is positive on the right side. The patient undergoes a CT scan (see below). In which cranial nerve would the patient be likely to develop a deficit?
- CN I
2. CN III - CN IV
- CN VI
- The CT scan shows a subdural hematoma with subarachnoid hemorrhage on the right. The complication would include an increase in the size of the hemorrhage as well as edema of the right temporal lobe. This may predispose to herniation of the medial temporal lobe leading to uncal herniation.
- Uncal herniation compresses CN III. The clinical presentation consists of a dilated ipsilateral pupil, which does not respond to light. On further compression, the affected eye will be looking down and out.
- Further herniation may compress the brainstem and cause a decrease in sensation.
- The uncus and the adjacent temporal lobe slide down the tentorial incisura and compress the posterior cerebral arteries and the brain stem. It carries a poor prognosis.
A 16-year-old with no significant past medical history presents to the emergency department with vomiting and severe headache preceded by a two-minute episode of a generalized tonic-clonic seizure 2 hours prior. He is accompanied by his mother who states that he has complained of occasional headaches for the past 3 years. His blood pressure is 90/60 mmHg, pulse rate is 110/min, and respiratory rate is 28/min. On physical examination, he is in moderate distress due to a headache and has evidence of lacerations on his tongue. He does not have any appreciable focal neurologic deficits. Where would you expect to find a lesion on magnetic resonance imaging (MRI) of this patient?
1. Cerebrum
2. Pons
3. Brain stem
4. Internal capsule
- This patient has an arteriovenous malformation of the brain. Arteriovenous malformations (AVMs) are a developmental anomaly of the vascular system, consisting of tangles of poorly formed blood vessels in which the feeding arteries are directly connected to a venous drainage network without any interposed capillary system.
- The majority of AVMs of the brain are found in the cerebral hemispheres. Seizures are due to cortical irritation, which would be less likely to occur from a lesion in the pons, cerebellum, or internal capsule.
- AVMs are the second most common cause of intracranial bleed after cerebral aneurysms, responsible for 10 percent of all cases of subarachnoid hemorrhage.
- Hemorrhages are usually intraparenchymal but can primarily occur in the subarachnoid space. Symptoms due to hemorrhage include loss of consciousness, sudden and severe headache, nausea, and vomiting as the coagulated blood makes its way down to be dissolved in the individual’s spinal fluid.
A 14-year-old presented with a spinal deformity. Her mother noticed this deformity at the age of 6 years. The deformity progressively increased in size. She is community ambulatory without any pain. She faces difficulty in standing from a sitting posture. She has one younger sibling with the same deformity. The radiograph is shown in the figure. Which of the following is the most appropriate treatment for this patient?
- Posterior spinal fusion T2-L5
2. Posterior spinal fusion T2-pelvis - Anterior spinal fusion T4-L5
- Posterior spinal fusion T4-pelvis
- This patient has clinical and radiological features of scoliosis secondary to Duchenne Muscular Dystrophy. These patients have typical difficulty in standing (Gowers sign). This is an X- linked recessive disease that may present with progressive weakness, scoliosis, equinovarus foot, and cardiomyopathy.
- The radiograph reveals coronal thoracolumbar scoliosis with pelvic obliquity. There is no hemivertebra which excludes the possibility of congenital scoliosis. Cobb angle is measured from the end vertebra of both curves to plan for surgery.
- Posterior spinal fusion from T2-sacrum is indicated in this patient. If the pelvic obliquity is more than 15 degrees then fusion should be done to include the sacrum which improves sitting balance and coronal alignment. Proximal fusion should be extended to T2 to prevent junctional kyphosis.
- If the forced vital capacity (FVC) is greater than 40, the scoliosis is greater than 25 degrees, and a 2-year life expectancy is projected, surgery is recommended. In contrast to a posterior- only technique, an anterior approach to the spine is not recommended in Duchenne patients because it requires lung deflation, which can lead to respiratory difficulties and increased blood loss.
A 27-year-old man is brought to the hospital after being assaulted with a metal pipe to his face. His chief complaint is left-hand side facial pain. His vital signs are within normal limits. On examination, there is edema and subconjunctival hemorrhage. A zygomatic-maxillary complex fracture is suspected. Which of the following is the next best step in the evaluation of this patient?
- Dental panoramic radiograph 2. Towne view
- Caldwell view
4. 15/30 occipitomental view
- 15/30 occipitomental views are used when a zygomatic- maxillary complex fracture is suspected.
- Zygomatic arch fractures have four components: lateral orbital wall, orbital floor, zygomatic arch, and the maxilla and zygoma separation.
- Zygomatic arch fractures are also known as quadripod fractures or quadramalar fractures.
- The occipitomental view is also known as the Waters’ view, and the x-ray passes from behind the patient’s head toward the radiographic plate.
A 35-year-old postpartum female presents with a progressive headache. On physical exam, there are no cranial nerve deficits. Her gadolinium-enhanced MRI of the brain is shown. Which of the following is the most appropriate therapy?
- Observation
- Non-steroidal anti-inflammatory medication
3. Glucocorticoid therapy - Surgical resection
- Lymphocytic hypophysitis is a rare autoimmune disease of the pituitary gland classically seen in peripartum women with headache or middle-aged men with diapedes insipidus.
- Lymphocytic hypophysitis may present with pituitary dysfunction, such as central diabetes insipidus, anterior pituitary hormone deficiency, and hypo/hyperprolactinemia. The degree of lymphocytic infiltration corresponds to the degree of pituitary enlargement, which may secondarily cause mass effect and contribute to visual loss, ophthalmoplegia, and headache.
- Lymphocytic hypophysitis is a diagnosis of exclusion, and histopathology with tissue biopsy is needed for a definitive diagnosis. Clinical information, laboratory data, and imaging, however, can help with the diagnosis. Gadolinium-enhanced MRI of the pituitary is the modality of choice, and may demonstrate an avidly-enhancing, thickened pituitary stalk, enlarged pituitary gland, and loss of the normal posterior pituitary “bright spot”. Gutenberg scoring was developed to correctly distinguish lymphocytic hypophysitis from pituitary adenoma.
- The main goal of treatment of lymphocytic hypophysitis is to manage pituitary hormone deficiencies and mass effect. Treatment consists of conservative management and anti- inflammatory medication. Surgery is employed for patients suffering from visual problems, compression of nearby structures, or equivocal imagining findings that require histology for diagnosis.
A 65-year-old female presented with the complaint of tingling, pain, and paresthesias over the dorsolateral aspect of her left hand and wrist for the last 1 month. She was administered a steroid injection in her left wrist for her condition. She now has paresthesias to the dorsomedial aspect of her left hand that worsens with wristwatch wear. From which cord of the brachial plexus does the offending nerve originate?
- Anterior
2. Posterior - Medial
- Lateral
- The radial nerve comes from the posterior cord of the brachial plexus.
- Compression of the superficial branch of the radial nerve at the level of the wrist is known as cheiralgia paresthetica. It is also commonly called Wartenberg syndrome or superficial radial nerve palsy.
- Chordoroff et al. reported a case in which a steroid injection to the 1st dorsal compartment of the wrist for de Quervain tenosynovitis causes subdermal atrophy in the surrounding area which later led to the development of cheiralgia paresthetica from the patient’s wristwatch.
- Cheiralgia paresthetica causes symptoms such as pain, burning, paresthesia, numbness, etc. to the dorsoradial aspect of the wrist, hand, and fingers.
A 54-year-old woman presents to the clinic with a one-year history of progressive swallowing difficulties. An MRI is obtained showing a T2 fat saturation hyperintense lesion as pictured. A needle biopsy is performed, which shows bubbly cells separated into lobules with fibrous septa and a myxoid stroma. Which of the following is the best initial therapy for this patient?
- Neoadjuvant radiation therapy
- Chemotherapy
- Conventional photon radiation
4. Highly-conformal radiotherapy
- Chordomas are relatively radioresistant which necessitates high-dose radiation including proton beam radiation or radiosurgery (highly conformal radiotherapy).
- When a needle biopsy is performed, the surgical resection should include the needle tract as chordomas can seed the needle biopsy tract.
- En bloc resection followed by high-dose radiation provides the best current long-term outcomes for chordoma treatment.
- Chordomas are slow-growing and chemotherapy is not a generally used treatment strategy. If chemotherapy is given, it is usually given as part of a clinically trial.
A 65-year-old man presents to the neurology clinic following acute onset blurring of his vision. The neurological examination revealed defects in the perception of color, form, and movement of objects. He is under medication for symptomatic dilated cardiomyopathy. Which of the following is the most likely anatomical region of involvement in the patient presenting with such neurological signs and symptoms?
1. Brodmann area 17
2. Brodmann area 22
3. Brodmann area 40
4. Brodmann area 45
- The patient likely has an acute ischemic stroke in the occipital cortex secondary to dilated cardiomyopathy.
- The defect in his perception of color, form, and movement of an object indicates the involvement of his primary visual cortex.
- Brodmann area 17 represents the primary visual cortex in the brain.
- Brodmann area 22 controls the lexical-semantic processing of sound. Brodmann area 40 is the supramarginal gyrus, and damage to this region can lead to alexia and agraphia.
A 48-year-old man is brought to the emergency department after a motor vehicle collision complaining of back pain but denies any abdominal pain and has no evidence of seatbelt sign. He reports fully intact sensation in bilateral lower extremities and demonstrates 5/5 strength in ankle plantarflexion and dorsiflexion. Straight leg raise is limited by back pain. The rectal tone is good. A radiograph is obtained and shown below. What is the most appropriate management strategy for this patient?
- Immobilization in a cast or TLSO brace
- Surgical decompression only
3. Surgical decompression and fusion - Surgical fusion without decompression
- While bony chance fractures are considered stable and may be managed non-operatively in the absence of a neurological deficit, ligamentous chance fractures, as seen here that disrupt the posterior ligamentous complex, are unstable and should be treated with surgical decompression and fusion.
- A Chance fracture of the spine is a flexion-distraction injury of the spine where the anterior spinal column fails in compression, and the middle and posterior spinal columns fail under tension.
- The center of rotation of chance fractures is through the abdominal viscera, and there is a high incidence in restrained passengers. Therefore, abdominal injuries must be also ruled out.
- Disruption to the posterior ligamentous complex renders the spine unstable, and stabilization must be provided surgically.
A 65-year-old man presented to the emergency department with severe neck pain following a slip and fall in the bathroom. He had severe axial neck pain, which worsened on neck rotations. His neurological status was normal, and the rest of the systemic examination was also within normal limits. He has a history of diabetes, hypertension, and ischemic heart disease, for which he underwent coronary angioplasty six years ago. He underwent a detailed evaluation of his cervical spine and was diagnosed with a type 2 fracture of the odontoid process. No other injuries were identified. The fracture was angulated at 10 degrees with a 1 mm fracture gap and 4 mm anteroposterior displacement. Which of the following is the most rational management strategy in the patient?
- Anterior odontoid screw fixation
- Halo-vest application
- SOMI Brace (Sternal Occipital Mandibular Immobilizer)
4. Hard cervical collar
- Odontoid fractures are managed conservatively or surgically based on various factors, including the degree of displacement, type of fracture (Anderson and D’Alonzo type 2 mainly), age of the patient, associated injuries, comorbidities, and presence of osteoporosis.
- Un-displaced fractures, defined as less than 2 mm fracture gap, less than 5 mm anteroposterior displacement, and less than 11- degree angulation, are best managed conservatively.
- The overall union rates following hard collars and halo-vest immobilization in stable odontoid fractures are reported to be reasonably similar. However, studies have revealed a much better reduction in the cervical range of motion after the halo- vest application. In younger individuals, the use of halo-vest immobilization is typically recommended, although, in the older population, hard cervical collar application is associated with the lowest complication rates.
- The major complications with halo-vest immobilization in the elderly include infection, aspiration pneumonia, and respiratory failure.
A 19-year-old ballet dancer with chronic lower back pain has exhausted non-operative options for treatment of her low-grade lumbosacral spondylolisthesis and underwent the surgical treatment pictured below. There were no intraoperative complications reported. Three weeks later, her lower back pain has improved, but she is complaining of new symptoms of numbness over the anterolateral aspect of her right thigh. What is the cause of this complication?
- Metalwork penetrating into the nerve root canal
- Progression of the disease
- Nerve root injury during the surgical slip reduction
4. Compression of a nerve during prolonged prone positioning intraoperatively
- Meralgia paresthetica is a well-known complication of prone positioning used for the posterior approach to the spine. Insufficient care with positioning of the bolsters may result in pressure over the lateral femoral cutaneous nerve (LFCN) of the thigh, causing numbness in its distribution. Symptoms usually resolve with time but can sometimes become painful while the nerve is recovering.
- Meralgia paresthetica is typically benign and self-limited with frequent spontaneous remission.
- Treatment focuses on patient reassurance and ways to reduce pressure and irritation over the nerve and groin region.
- Medications that may be helpful include nonsteroidal- antiinflammatory drugs (NSAIDs), topical capsaicin, lidocaine, or tacrolimus for epidermal dysesthesia or cutaneous hypersensitivity.
A 48-year-old woman presents with chronic headache. She denies fever, vision loss, and facial swelling. Serum prolactin is 200 ng/mL and growth hormone is 6 mcg/dL. An MRI of the brain is shown. Which of the following is the most likely diagnosis?
- Cavernous sinus thrombosis
- Meningioma
3. Pituitary adenoma - Lymphocytic hypophysitis
- Pituitary adenomas are benign tumors of the adenohypophysis. A macroadenoma is a sellar mass greater than 10 mm without a separate identifiable pituitary gland.
- Pituitary adenomas are often found incidentally on imaging. Up to 75% are endocrinologically active, and may be prolactin-, growth hormone-, or ACTH-secreting. Visual field defects (bitemporal hemianopsia) may present secondary to mass effect in cases of large tumors. Headache is commonly reported though is nonspecific.
- In this case, contrast-enhanced T1W MR demonstrates a hypoenhancing mass inseparable from an enhancing and enlarged pituitary gland, with minimal superior extension. The mass contacts and surrounds the right supraclinoid internal carotid artery without compression.
- Dopamine agonists are the first-line treatment for prolactin- secreting tumors. Transsphenoidal resection is recommended in patients with macroadenomas and visual field deficit, ophthalmoplegia, optic nerve compression, pituitary apoplexy, or loss of endocrine function.
A 16-year-old boy is brought to the emergency department after being knocked off his bike by a car. His eyes are closed with clear trauma to his head and a clear, bloodstained fluid running from his nose. He is making no verbal effort and has stertorous breathing. On stimulation of the trapezius, he extends at the elbow with forearm pronation and wrist flexion. His knees extend with internal rotation at the hips and plantar flexion of the feet. What is the most likely location of the lesion causing this patient’s presentation?
- Bilateral frontal lobes
2. Below the red nuclei - Below the vestibular nuclei
- Cervical spine
- Decerebrate posturing is characterized by adduction and internal rotation of the shoulder, extension at the elbows with pronation of the forearm, and flexion of the fingers. The lower limbs show extension and internal rotation at the hip with knee extension and plantar flexion of the feet. Toes are typically abducted and hyperextended.
- Decerebrate posturing suggests damage to the corticospinal and rubrospinal tracts with the preservation of the vestibulospinal tract. This places the lesion below the red nucleus but above the vestibular nuclei in the rostral medulla. Therefore a pontine lesion is most likely.
- Overall, children requiring admission to hospital due to head injury have a mortality of 10 to 13%; however, in severe cases with decerebrate posturing, the mortality is 71%. Factors that favor survival in traumatic brain injury with decerebrate posturing include younger patient age, admission within 6 hours of injury, and extradural hematoma. Poorer outcomes are seen in acute subdural hematoma and older age.
- Clear bloodstained fluid running from the nose of a patient with a head injury likely indicates a base of skull fracture.
A 27-year-old female patient with no past medical history presents to the emergency department with left eye pain and decreased perception of light. The exam is also remarkable for poor rapidly alternating movement of the right hand and slurred speech. Both eyes show ocular dysmetria, and tandem gait is very unsteady. On ocular examination, when an attempt is made to gaze contralaterally, the affected eye adducts minimally. The contralateral eye abducts, however, with nystagmus. What is the next step in the management of this patient?
- Dilated fundoscopic examination
2. Magnetic resonance imaging of the brain and orbits - Lumbar puncture
- EEG
- Optic neuritis is often the presenting symptom of multiple sclerosis. Another common visual complaint is abnormal eye movement, known as internuclear ophthalmoplegia (INO). Patients often complain of diplopia. INO results from a demyelinating lesion of the medial longitudinal fasciculus.
- A contrast-enhanced magnetic resonance imaging (MRI) scan is the most appropriate next step in the management of this patient.
- The presence of typical lesions on an MRI negates the need for lumbar puncture in most cases.
- A lumbar puncture can be obtained if the MRI is equivocal.
A 39-year-old man presents with neck stiffness, bilateral arm pain, difficulty buttoning shirts, and gait instability. He has 4+/5 strength in the upper extremities and is hyperreflexia at his biceps, brachioradialis, and patella. He also has a positive Hoffman sign bilaterally. MRI is shown below. Which of the following is the most rational next step in the management of the patient?
1. CT spine
2. HLA-B27 status
3. Posterior cervical laminectomy
4. Anterior corpectomy and bone graft fusion
- The clinical and radiological features in the patient are highly suggestive of cervical myelopathy resulting from an ossified posterior longitudinal ligament (OPLL).
- The CT spine is the most rational next step in the management of the patient presenting with such clinical characteristics.
- CT spine helps in diagnosing as well as categorizing the patterns of involvement of the vertebral bodies and the disc spaces, thereby helping to formulate the appropriate surgical intervention in the patient.
- Anterior or posterior surgical approaches in the management of OPLL depend upon its subtypes as classified by the CT findings. It also depends upon the age, neurological status, medical comorbidities, and the cervical lordosis of the patient.
A 16-year-old man from Nepal presents to the neurology clinic with worsening headache, low-grade fever, and vomiting for the last three weeks. The relatives noticed three episodes of right focal seizures a week back. He denies any history of intravenous drug abuse or any psychiatric medication use. There is no neck rigidity or neurological deficit on clinical examination. The fundus examination shows Grade 1 papilledema. A further systemic examination is within normal limits. The tuberculin skin test shows an induration of 15 mm. The chest radiograph shows a healed fibrotic lesion in the upper lobe of the right lung. The HIV serology is negative. A T1W post-contrast axial MRI image reveals hypointense ring enhancing lesions in the left parietal lobe with significant perilesional edema but no hydrocephalous or midline shift. A lumbar puncture for cerebrospinal fluid (CSF) analysis is withheld in view of the significant perilesional edema on the imaging. What is the most rational next step in the management of the patient?
1. Start empirical 4-drug anti-tubercular therapy with steroids
2. Referral to neuroradiologist for stereotactic brain biopsy
3. Plan the surgical excision of the lesion
4. To do peripheral blood Interferon-Gamma release assay
- Diagnosis of tuberculoma is based on characteristic imaging of ring-enhancing lesions on contrast-enhanced CT scan or MRI of the brain.
- When the diagnosis of tuberculoma is not possible with imaging or response to ATT is unsatisfactory, there is a progression of brain lesion, the definitive diagnosis can be made by stereotactic biopsy depending upon the availability of such a modality.
- Brain tuberculomas are managed pharmacologically with first- line ATT and dexamethasone.
- Surgery is indicated when tuberculoma >20 mm or if it is causing a mass effect in the form of midline shift or obstruction to CSF flow or when medical therapy fails.
