Absolute Case-Based Neurology Review : An Essential Q & A Study Guide

146 Pages·2019·1.183 MB·English

by  Doris Kung, Thy Nguyen, Ritu Das

Absolute
Case-Based
Neurology Review
An Essential Q & A Study Guide
Doris Kung
Thy Nguyen
Ritu Das
123
Absolute Case-Based Neurology Review
Doris Kung • Thy Nguyen • Ritu Das
Absolute Case-Based
Neurology Review
An Essential Q & A Study Guide
Doris Kung Thy Nguyen
Department of Neurology Department of Neurology
Baylor College of Medicine The University of Texas Health
Houston, TX Science Center
USA Houston, TX
USA
Ritu Das
Adventist Health
Paradise, CA
USA
ISBN 978-3-030-11131-1 ISBN 978-3-030-11132-8 (eBook)
https://doi.org/10.1007/978-3-030-11132-8
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Preface
In our daily lives, we all wear many hats. One of our shared hats is a passion for
neurology patients. We developed this passion together during our neurology resi-
dency training at Baylor College of Medicine. Several years later, with many of our
own children running around, we brainstormed about how we could help share our
love for neurology patients with others.
We find that neurology is a daunting field for many learners. Collectively, we
have encountered learners from many levels: observers, medical students, residents,
and fellows. It is always striking how much learners develop such a deep foundation
of knowledge from their patient encounters. It can take rereading a paragraph from
a textbook several times for it to “stick.” However, the story of that one unique
patient may be one a learner recalls and shares lifelong.
Our goal is to provide interesting patient stories and frame them in “cases” so
that students can recall neurologic knowledge. We use up-to-date and evidence-
based questions to help our learners. We encourage them to use this book as a pri-
mary study tool, along with references to help them in their neurology rotations,
tests, and daily practice. Questions are grouped into important topics in neurology
so that learners who need to focus their studying in a particular area can do so.
Answers and references are provided at the end of each section.
We hope that our enthusiasm for neurology patients, like a bad virus, is
contagious.
We would like to thank Dr. Joseph Kass for his guidance. We thank our students,
particularly Chloe Nunnely, Austin Jones, and Ethan Edmondson, for reviewing and
helping us refine the questions. We thank our families who have always encouraged
us and we love you immensely!
Houston, TX, USA Doris Kung
Houston, TX, USA Thy Nguyen
Paradise, CA, USA Ritu Das
v
Acknowledgments
From Dr. Kung:
Thank you to my friends, family, my wonderful children, and my loving husband.
Thank you God for blessing my work and family life.
From Dr. Nguyen:
I want to thank the neuromuscular team and my colleagues at UT for guidance,
mentorship, and helping me to take the best care of my patients. I want to thank the
medical students, residents, and fellows at UT for inspiring me every day to teach
and learn. Thank you to the most supportive husband, Jim, for supporting me to
pursue any of my goals even if it means more babysitting for him. Thank you to the
best kids in the world: Jett, Kaia, and Leia. Thank you to my parents, John and Lan,
who have sacrificed so much to give me opportunities. Most of all, thank you to my
patients who let me share in their journeys.
From Dr. Das:
I would like to acknowledge the love of my family, their faith, and unending positiv-
ity. I am grateful for each patient along this path who has enriched my understand-
ing and perspective. I am as well immensely grateful, even for the brief time I have
had to know the beautiful spirit of Paradise, California.
vii
Contents
1 Neuroanatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2 Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3 Demyelinating Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
4 Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
5 Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
6 Vertigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
7 Pediatric Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
ix
x Contents
8 Movement Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
9 Neuromuscular Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
10 Spinal Cord/Cauda Equina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
11 Ischemic Stroke and Hemorrhagic Stroke . . . . . . . . . . . . . . . . . . . . . . 95
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
12 Increased Intracranial Pressure (ICP) . . . . . . . . . . . . . . . . . . . . . . . . . 107
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
13 Head Trauma and Brain Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Head Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Brain Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
14 Meningitis and Encephalitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
15 Toxic and Metabolic Encephalopathy . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Neuroanatomy 1
Questions
1. You are asked to consult on a woman with altered mental status and weakness.
In the ER, she is found to have hyponatremia to 112. Over the next 24 hours, her
sodium level becomes 140. On examination, she has normal vital signs. She is
moaning and incoherent. Eye movements seem full. She has significant quadri-
paresis and does not move any extremity to painful stimuli. Her reflexes are
increased. Which of the following diagnostic studies would be most helpful in
ascertaining the etiology of change in her motor examination?
A. Repeat BMP as her motor symptoms may be related to her sodium level
dropping again to 112
B. CT head without contrast stat to evaluate for new onset bilateral lobar
hemorrhage
C. MRI brain without contrast with attention to the brainstem to evaluate for
demyelination in the corticospinal tract
D. Electrodiagnostic studies (electromyography (EMG) and nerve conduction
studies) to assess for critical illness polyneuropathy/myopathy
2. A 33 year-old woman presents to your office with difficulty walking. She
reports that 10 years ago, she underwent a gastric bypass procedure (Roux en
Y) and lost 150 pounds since that time. She has not been compliant with post-
operative visits with her bariatric surgeons. She reports that she is not currently
taking any medications. Her vital signs are stable. Her neurologic examination
shows normal strength except for mild weakness in distal bilateral lower
extremities: dorsiflexion, plantar flexion, toe flexion and toe extension. Reflexes
are brisk in the upper extremities with crossed adductors in the patella and
absent at the ankles. Sensory examination shows reduced vibration and
proprioception up to the knees bilaterally. Her gait reveals reduced hip flexion
© Springer Nature Switzerland AG 2019 1
D. Kung et al., Absolute Case-Based Neurology Review,
https://doi.org/10.1007/978-3-030-11132-8_1
2 1 Neuroanatomy
and knee flexion movements with some steppage. Which of the following find-
ings might be seen on a pathologic level to explain her symptoms?
A. Loss of myelin in the corticospinal and dorsal column tracts in the spinal
cord
B. Abnormality in the corticospinal tract and degeneration of the anterior horn
cells
C. Multifocal demyelinating plaques located throughout the brain and spinal
cord affecting multiple different long tracts
D. Degeneration of the spinocerebellar tracts and dorsal column tracts in the
spinal cord
3. A 70 year-old man presents to your clinic with imbalance. This has been slowly
progressive over at least 5–6 years, but he cannot really tell a date of onset. His
social history reveals that he drinks about “a fifth” of liquor per day since his
30s. He has been cutting down. On examination, he has normal cranial nerves
without nystagmus. Strength and reflexes are normal. Sensation shows some
reduced pinprick and temperature distal to the ankles. His finger to nose, rapid
alternating movements and heel to shin are normal. He has significant difficulty
with tandem gait and can only perform 2 or 3 steps before lurching. Which of
the following alcohol related findings may explain his primary complaint of
imbalance?
A. Alcohol is directly toxic to the small nerve fibers
B. Alcohol can lead to vitamin deficiencies that cause a sensory-motor
polyneuropathy
C. Alcohol can lead to degeneration in the cerebellum, particularly the cere-
bellar lobes
D. Alcohol can lead to degeneration in the cerebellum, particularly the cere-
bellar vermis
4. A 30 year-old woman presents for evaluation of headache for 3–4 months. She
reports constant progressive headache that have not responded to over the coun-
ter ibuprofen or acetaminophen. She also reports visual loss that occurs in her
“peripheral vision”. She denies improvement with rest and sometimes awakens
in the middle of the night with her headache. Her neurologic examination shows
normal strength, reflexes, coordination and sensation. On visual field testing,
you notice that she has difficulty making out fingers in her bitemporal fields.
Which of the following etiologies could explain her symptoms?
A. Intractable status migrainosus with scotoma
B. Pituitary adenoma compressing on the optic chiasm
C. Idiopathic intracranial hypertension (pseudotumor)
D. Bilateral occipital lobe hemorrhage