Questions 01/24/2013

Neurology

Question 1
A 57-year-old woman presents to the emergency department 45 minutes
after onset of severe expressive aphasia, right hemiparesis, and
hemi=sensory loss. Her NIH stroke scale score is 16. Past medical
history is significant for coronary artery disease, coronary angioplasty
and stent placement 4 years ago, and surgery on her left foot 5 days ago.
On initial presentation, the patients blood pressure was 190/100 mmHg
and is now 170/90 mmHg. The patient reports taking aspirin and
clopidogrel for coronary artery disease. Emergent laboratory studies,
electrocardiogram, and CT scan of the head performed over the next half
hour are normal. After the initial evaluation and testing, the patients NIH
stroke scal is 3. Which of the following is a contraindication to this
patient receiving recombinant tissue plasminogen activator (rt-PA)?
a) Current use of aspirin and clopidogrel
b) Blood pressure 170/90 mm Hg
c) Rapidly resolving symptoms
d) Recent minor surgery

Answer 1
Exclusion criteria for fibrinolytic therapy
1. Evidence of intracranial hemorrhage on non-contrast head CT
2. Only minor or rapidly resolving stroke symptoms
3. High clinical suspicion of subarachnoid hemorrhage even with
normal CT findings
4. Active internal bleeding (e.g. gastrointestinal or urinary
bleeding within the last 21 days)
5. Known bleeding diathesis, including but not limited to
Platelet count < 100,000/uL
Patient has received heparin within 48 hours and had an elevated
activated partial thromboplastic time (greater than the upper limit
of normal for laboratory)
Recent use of anticoagulant (e.g., warfarin) and elevated
prothrombin time > 15 seconds or INR > 1.7

Answer 1
6. Within 3 months of intracranial surgery, serious head
trauma, or previous stroke
7. Within 14 days of major surgery or serious trauma
8. Recent arterial puncture at noncompressible site
9. Lumbar puncture within 7 days
10.History of intracranial hemorrhage, arteriovenous
malformation, or aneurysm
11.Witnessed seizure at stroke onset
12.Recent acute myocardial infarction
13.On repeat measurements, systolic blood pressure > 185
mm Hg or diastolic pressure > 110 mm Hg at time of
treatment, requiring aggressive treatment to reduce blood
pressure to within these limits

Question 2
A 66-year-old man with a history of atrial
fibrillation presents to the emergency department
with acute onset right-sided weakness and
sensory loss that occurred 25 minutes prior to
presentation. He is alert and swallows normally.
His blood pressure is 195/120 mm Hg with a heart
rate that is irregular at 90 bpm. Serum glucose is
358 mg/dL. The patient is currently on warfarin
and prothrombin time is elevated beyond
therapeutic range. Head CT demonstrates is as
shown. All of the following are indicated in the
immediate management of this patient except:
a) IV vitamin K
b) Insulin
c) IV labetalol
d) Phenytoin

Answer 2
Intracerebral hemorrhage
Endotracheal intubation for decreased level of
consciousness or poor airway protection
Cautious lowering of blood pressure to a MAP of less than
130 mm Hg
Maintain euvolemia using normotonic fluids
Avoid hypertheria, hypothermia
Correct hyperglycemia
Correct coagulopathy with FFP, vitamin K, protamine or
platelet transfusions
Initiate fosphenytoin or other anti-convulsant for seizure
activity of lobar hemorrhage
Transfer to ICU or OR

Question 3
A 32-year-old patient is brought by his fiance after a witnessed
tonic-clonic seizure. The patient experienced bladder
incontinence and was lethargic for 15 minutes. On physical
exam you note that she has bitten her tongue, but has a normal
neurologic exam. Head CT is negative for bleeding or structural
abnormalities and lab work is within normal limits. What is the
most appropriate next step in the management of this patient?
a) Administer a loading dose of phenobarbital and phenytoin and
discharge with a prescription for both.
b) Admit the patient for observation despite full recovery
c) Discharge the patient with instructions for prompt follow-up
and instruct not to drive until further notice
d) Obtain an EEG in the ED
e) Perform a lumbar puncture for CSF analysis

Answer 3
ACEP Clinical Policy Seizure Management
Which new-onset seizure patients who have
returned to a normal baseline need to be admitted
to the hospital and/or started on an antiepileptic
drug?
Level A recommendations. None specified
Level B recommendations. None specified
Level C recommendations.
Patients with a normal neurologic examination can be
discharged from the ED with outpatient follow-up.
Patients with normal neurologic examination, no comorbidities,
and no known structural brain disease do not need to be
started on an antiepileptic drug in the ED

Question 4
An 80-year-old male presents for evaluation of
worsening ataxia. His family notes that he is easily
confused and has difficulty with bladder control.
Which of the following is the best diagnostic test
for this patient?
a) CT scan of the brain
b) Electromyogram (EMG) and nerve conduction
velocity (NCV)
c) Psychiatry consult
d) GU consult
e) Cobalamin level

Answer 4
Normal pressure hydrocephalus
Urinary incontinence, cognitive
disturbance, gait difficulty (wet,
wacky, wobbly)
Male to female ratio the same
Increases with age
Image with CT or MRI
Treated with ventricular shunting

Question 5
The most common cause of new-onset
seizures in the elderly patient is
a) Alzheimer dementia
b) Malignancy
c) Drug toxicity
d) Stroke
e) Trauma

Answer 5
Seizure
Ischemic or hemorrhagic stroke is the
cause of new-onset seizures in 4054% of elderly patients
Most common cause of status
epilepticus is discontinuation of
anticonvulsant medication

Question 6
Which of the following is characteristic
for Wernicke encephalopathy?
a) Normal mental status
b) Tachycardia
c) Ophthalmoplegia
d) Normal reflexes
e) Headache

Answer 6
Wernicke encephalopathy
Vitamin B1 (thiamine) deficiency
Criteria require 2 of the following signs
Dietary deficiency
Oculomotor abnormalities
Cerebellar dysfunction
Altered mental state or mild memory
impairment

Requires admission and aggressive

thiamine and magnesium repletion

Question 7
An 8-year-old male comes to the ED after passing out at
school. He ate lunch and felt fine, but in class felt his heart
racing. He became sweaty and nauseous, then slumped
over at his desk. On EMS arrival, his heart rate was 210,
and he was awake. In the ED his heart rate is 120 and
regular, and the ECG is normal. The most appropriate
study for this patient is which of the following?
a) Blood glucose
b) Chest radiograph
c) Serum electrolytes
d) Echocardiogram
e) Holter monitor

Answer 7
Pediatric syncope
Estimated that 15% of pediatric population experience one episode of
syncope
Routine labs are not required for clear episodes of vasovagal syncope.
Consider chemistry, hematocrit, thyroid function tests, chest
radiograph, and ECG
Risk factors for serious cause of syncope
Exertion preceding the event
History of cardiac disease in the patient
Family history of sudden death, deafness, or cardiac disease
Recurrent episodes
Recumbent episode
Prolonged loss of consciousness
Associated chest pain or palpitations
Use of medications that can alter cardiac conduction

Question 8
An 18-month-old boy is brought to the ED after
passing out. Mom states the child had been playing
happily when she called him for dinner. He said no,
and mom took his toys away and he began to cry. His
face turned blue and he fell to the ground. In the
emergency department he is acting normally and his
vital signs are normal. Pulse oximetry on room air is
100%. This is an example of which of the following?
a) Cyanotic breath-holding spell
b) Pallid breath-hold spell
c) Situational syncope
d) Arrythmia

Answer 8
Breath holding spells
Typical occurrence in 6-18 month olds
Cyanotic vs. pallid
Cyanotic breath holding held in expiration with
associated cyanosis. May also have loss of
consciousness, limpness, opisthotonic posturing and
recovery within 1 minute
Pallid Form of reflex syncope usually provoked by
antecedent trauma, pain, or fright. May be associated
with clonic movements and incontinence. Return of
consciousness occurs in less than 1 minute but may
be associated with persistent fatigue for several hours

Question 9
A 4-year-old male had hand-foot-mouth disease 2
weeks ago. This has resolved, but this morning the
child had an unsteady gait. In the ED, the child has
a normal exam except for ataxia upon walking, and
mild truncal ataxia when sitting. Of the following,
which is the most likely etiology of his ataxia?
a) Drug ingestion
b) Acute cerebellar ataxia
c) Brain tumor
d) Guillain-Barre syndrome
e) Brain abscess

Answer 9
Acute cerebellar ataxia
40% of ataxia cases in children are due to
acute cerebellar ataxia
Autoimmune phenomenon leading to
cerebellar demyelination
Boys more commonly affected
Highest incidence at ages 2 to 4 years
70% have history of recent illness
Up to 26% are associated with varicella

Question 10
An 18-year-old female has a history of
migraines. She states that they are triggered
when she eats hot dogs. Besides meats with
sodium nitrite, other foods she should avoid
include
a) Goat cheese
b) Mexican food
c) American cheese
d) White wine
e) Chinese food

Answer 10

Tyramine (aged cheese)

Sodium nitrite (hot dogs, smoked meats)
Monosodium glutamate (Chinese food)
Caffeine
Chocolate
Red wine
Drugs (oral contraceptives,
antihypertensive medications, cimetidine,
H2 blockers)