Multiple Topics

A 75-year-old man with a past medical history of hypertension, hyperlipidemia, and diabetes presents with acute onset right arm weakness and speech problems. He can speak fluently and his comprehension is intact. However, he is unable to repeat even simple sentences. Reading and writing are preserved. Which of the following is an accurate description of his speech dysfunction?

A 72-year-old male with a past medical history of hypertension presents with an acute onset of right upper and lower extremity weakness. The sensory exam is normal. Right homonymous hemianopia is also appreciated. Which of the following vessels is most likely affected?

A 37-year-old female with a past medical history of obesity presented to the emergency room with a severe headache and visual disturbances. The funduscopic exam shows bilateral papilledema. An MRI of the brain shows an empty sella and MRV was normal. A lumbar puncture was performed. The opening pressure was 38 and there were no WBCs or RBCs appreciated in the CSF. What is the most appropriate therapy for her disease?

The pathology shown in the image below is likely secondary to which of the following?

Which of the following findings is depicted in the catheter angiogram shown?

A 32-year-old man with no significant past medical history presents to the emergency department after experiencing a generalized tonic-clonic seizure. His neurological examination was unremarkable. As part of his work-up, an MRI was obtained (see FLAIR axial image below). What is the most appropriate next step in management?

A 56-year-old man with a past medical history of hypertension and type II diabetes presents to the hospital with acute onset left-sided weakness which started 90 minutes prior to your evaluation. His only medications prior to admission were metformin and verapamil. Vitals were within normal limits except for a blood pressure of 154/92. Physical examination reveals 3/5 weakness in the left arm, leg, and face as well as a moderate sensory disturbance in the same regions. CT head was unremarkable and CT angiogram (CTA) showed no large vessel occlusion. A brief history gathered from his wife revealed no other comorbidities or active medical issues. At this point in his clinical presentation, what is the mechanism of action of the most appropriate therapy?

A 32-year-old woman comes into the clinic complaining of severe right-sided headaches around the temple. The pain occurs several times a day and lasts approximately 15 minutes and radiates to the right shoulder and arm. There is also associated nasal congestion and lacrimation during the episodes. The patient was treated with indomethacin with complete resolution of symptoms. What is the most likely diagnosis?

A 27-year-old female presented with a severe headache for the past 4 days. Last week she gave birth to a healthy baby boy. She says the pain is worse when sitting up or walking but laying down in bed provides some relief. A brain MRI with contrast is ordered which shows thickening and enhancement of the dura. What is the most appropriate therapy for this patient?

You are caring for a patient in the Neuro ICU for loss of consciousness after 3 convulsive episodes within a 2 hour period. She required intubation with rocuronium and sedation with propofol. She was loaded with 2000 mg of Keppra and had received 2 mg of Ativan in the ED. You obtain a spot EEG and left temporal epileptiform discharges are seen, but no additional seizures. Unfortunately, your hospital does not have continuous EEG capabilities. Of the following options, which physical exam change in this paralyzed patient is most likely to indicate potential repeat seizure and prompt stat repeat spot EEG and consideration of antiepileptic bolus?

Which of the following is not one of the absolute exclusionary criteria for tissue plasminogen activator (tPA)?

Which of the following arteries supplies the head of the caudate nucleus and the anterior limb of the internal capsule?

A patient with a history of hypertension and provoked seizures secondary to posterior reversible encephalopathy syndrome (PRES) has come to your clinic for a 6-month follow-up after her associated hospitalization. It was found that abrupt discontinuation of her hypertensive medications due to medication noncompliance was the cause of the PRES. She was started on the anti-seizure medication (ASM) levetiracetam at the time of her PRES and has had no seizures since being discharged. She asks you about the risk of future seizures. What is the most appropriate response?

An 83-year-old man presented with an acute onset of difficulty walking and nausea about 12 hours prior to being seen in the emergency room. Examination revealed vertigo and truncal ataxia. An MRI was performed to evaluate for stroke. The FLAIR axial MR image is shown below. What is the vascular territory damaged in the imaging provided?

A 39-year-old male presents with right-sided weakness and aphasia. NIHSS is 22 on physical exam. He was last known well 2.5 hours prior. The past medical history does not reveal any contraindications to tPA. A CT head is done and shows a hyperdense left MCA sign. The tPA is mixed by the nursing staff while you consent his wife for its administration. When you return to the bedside his aphasia has improved but his NIHSS is still 13. The blood pressure is 189/105 and the glucose is 225. What is the most appropriate next step?

A pediatric neurology consult was placed for a 5-day-old, full-term newborn with macrocephaly. When formally measured his head circumference was 46 cm. A tense fontanelle was appreciated on examination. A bedside ultrasound was performed and the only abnormality appreciated was significant hydrocephalus. What is the most likely etiology of the patient’s symptoms?

A patient with an AVM rupture is admitted to the ICU. On exam, the patient has abnormal neck, elbow, and knee extensor posturing, and wrist flexion. In which of the following locations was the AVM most likely located?

Which of the following medications may be unsafe for the treatment of migraine headaches in patients with a history of coronary artery disease (CAD)?

A 65-year-old right-handed man presents with acute onset speech difficulties, a mild right-sided facial droop, and right-sided arm weakness. While talking to his wife over breakfast this morning he suddenly stopped speaking and could only make unintelligible sounds. On examination, he is unable to speak any words but has intact comprehension. He is able to write clearly what he wants in full sentences with intact grammar and reading is also preserved. Which of the following best describes his language deficit?

How long ago did the ischemic injury seen on the micropathology slide below of neuronal tissue occur?

Which of the following identifies the straight sinus?

A 67-year-old man presents urgently to the emergency room with an acute onset of left-sided weakness and numbness. A CT head was performed and shown below. What is the most likely etiology of the patient’s symptoms?

Which of the following arteries is the first branch of the internal carotid after it enters the cranial cavity?

Which of the following are actions of the superior rectus muscle?

Which of the following is the correct order of venous structures related to cerebral blood drainage?

A 68-year-old woman with a history of diabetes and hypertension presented urgently to the ED with a 2-day history of headaches and confusion. Before any imaging was able to be completed in the emergency room, the patient had a cardiac arrest and died. An autopsy was requested by the family. A gross pathologic image of the patient’s brain is shown below. What is the most likely etiology of the findings seen in this image?

A 42-year-old male presents as a trauma for a large motor vehicle accident. He is comatose, intubated but not sedated, and admitted to the trauma ICU. His brain imaging shows diffuse axonal damage. On examination, his pupils are reactive equally and corneal reflexes are intact, but otherwise, he has no motor response to pain, upgoing plantar reflexes bilaterally. The family asks if the patient is “brain dead”. Which of the following is not part of the confirmatory criteria on the standard brain death exam?

A 40-year-old man comes into the clinic with headaches. He has stabbing pain around the left temple that occurs numerous times during the day. The pain lasts 10-30 seconds at a time. He says he has excessive tearing from the left eye during these episodes. What is the most appropriate therapy?

A 5-year-old female was brought to the neurology clinic for a second opinion for paroxysmal spells of dizziness. The family states that several times a month the patient will develop severe dizziness, nausea, and vomiting. Symptoms usually only last less than 5 minutes. An MRI and 24-hour ambulatory EEG have been performed in the last 3 months. Both were unremarkable. What is the most likely diagnosis?

Identify the structure labeled 4 in the angiograms provided below.

A 41-year-old female smoker with HTN is admitted to the Neuro ICU after having acute onset worst headache of life, found to have hyperdensity tracking sulcal lines on CTH. Her physical exam is otherwise normal on admission. On the fourth day of admission, she develops acute onset right arm and leg weakness and aphasia. She was last seen well 30 minutes prior. Which of the following is true?

Which of the following is the reversal agent for apixaban?

A 40-year-old male with a history of headaches, seizures, and recurrent strokes has a brain biopsy performed to aid in diagnosis. Electron microscopy of his brain tissue shows granular osmiophilic material in the basal lamina of small cutaneous arterioles. What is the cause of this patient’s disease?

A patient presents with double vision that improves when tilting their head to the right. A lesion is most likely to be present in which of the following cranial nerves?

A 44-year-old woman who was recently started on a new abortive therapy for her migraines presents with a new type of headache described as more severe and with an extremely rapid onset. CT head imaging revealed no acute findings and lumbar puncture testing was unremarkable. Which of the following is the most likely diagnosis?

A 65-year-old woman with a past medical history of hypertension, hyperlipidemia, and migraine headaches previously well-controlled on propranolol, presents to the clinic with new headache characteristics. The patient states that she recently has a new scalp tenderness. On further history, she endorses jaw soreness after eating. What is the most appropriate initial diagnostic test?

The brain MRI (susceptibility-weighted imaging) shown below is most likely associated with which of the following conditions?

Which of the following is the correct order of internal carotid artery segments (from proximal to distal)?

A lesion to which of the following arteries could produce the ischemic findings shown in the MRI below (Brain MRI, axial cuts. Left: DWI sequence. Right: ADC sequence).

A previously healthy 59-year-old male presents with an acute onset of slurred speech and left-sided weakness. The symptoms started 7 hours ago. On arrival, his NIHSS is 8 and his EKG shows a normal sinus rhythm. Vessel imaging is done and shows a right middle cerebral artery occlusion, so the patient undergoes a successful mechanical thrombectomy and has minimal residual neurological deficits. A post-thrombectomy CT head is performed and negative for blood. Which of the following options is the most appropriate next step in medical management?

Which of the following has the longest half-life?

Which of the following medications has been shown to improve neurological outcomes in patients with subarachnoid hemorrhage?

A 55-year-old female with a past medical history of coronary artery disease and ischemic stroke with residual mild left arm weakness presents with headaches for a year. Episodes occur two to three times a month. The pain is unilateral and is associated with nausea and photophobia. During this episode, she is unable to go to work and over-the-counter anti-inflammatories have been ineffective. Physical exam and vitals are normal. Which abortive therapy is the most appropriate next step in management?

Which of the following correctly identifies the cranial nerve(s) that transverse through the structure (blue arrow) shown below?

A 45-year-old female with a past medical history significant for asthma presents to the clinic for migraines with aura. Her headaches occur at least 13 times a month. She was given sumatriptan for abortive therapy six months ago but it has become ineffective. Her vital signs are stable. Her BMI is 33. Which of the following is the best next step in treatment?

A patient with a recent history of ischemic stroke with almost no residual focal deficits except for a mild right-sided facial droop presents to the emergency room with altered mental status. Vital signs are only impressive for a low-grade fever. CT head and CTA show no acute changes when compared to imaging completed for his initial stroke. Blood work shows thrombocytopenia, anemia, and renal failure. A severe drug reaction is suspected. Which of the following medications is most likely the cause of this clinical presentation?

A 45-year-old man comes into the ED complaining of a severe headache. A spinal tap shows xanthochromia. The patient is treated immediately and spends the next two weeks in the neurocritical care unit. On day nine of his stay, his speech becomes slurred and the neurologist notices that the left side of his face is drooping. What is the class of drugs that could have potentially prevented these findings?

Which of the following is the thalamic relay center for proprioception of the face?

A critically ill 1-month-old has cerebral vessel imaging performed and shown below. Which of the following comorbid medical issues are likely present?

A 48-year-old patient with a past medical history of chronic migraines is brought in by her family with sudden-onset memory complaints. She is unable to recall where she lives or even her own name. A brain MRI (Left: DWI. Right: ADC.) is shown below. Which of the following is the most likely diagnosis?

A 79-year-old woman presented with the acute onset of difficulty walking and nausea that started about 24 hours before presentation. Examination revealed left-beating nystagmus and left-sided appendicular and truncal ataxia. Her axial FLAIR MRI imaging is shown below. The pathology shown is seen in which of the following vascular territories?

The vessel imaging shown below is consistent with which of the following?

A 37-year-old female with a past medical history of acne, obesity, anxiety, and fibromyalgia presented to the emergency room with a severe headache, papilledema, and visual disturbances. MRI shows an empty sella and MRV was normal. Symptoms started two weeks after her primary care physician initiated a new medication. Which of the following was the most likely medication initiated by the primary care physician?

Which of the following is present in the image shown below?

According to Practice Parameters by the American Academy of Neurology, Which of the following is not recognized as a reliable assistive device in accurately predicting a poor outcome in comatose patients after cardiopulmonary resuscitation for cardiac arrest?

An abnormal breathing pattern described as irregular inspiratory phases and variable intervals of apnea can localize to damage to which of the following regions along the neuraxis?

What is the mechanism of action of apixaban?

Which of the following findings is depicted in the vessel imaging shown?

Which of the following criteria for brain death based on EEG recording is incorrect?

Of the following, which extraocular muscle is not innervated by the oculomotor nerve?

What is the mechanism of action of dabigatran?

Which of the following findings is depicted in the catheter angiogram shown?

What is the pathophysiology of the lesion provided below?

A 61-year-old male with hypertension, hyperlipidemia, diabetes, and coronary artery disease presents after a sudden onset of headache and difficulty speaking, with left arm and leg weakness. Their blood pressure is 212/105 mmHg, and their blood glucose is 275 mg/dL. You notice aspirin on his medication list. A CTH is performed and is notable for a 25 cc hemorrhage in the right basal ganglia. Which of the following is correct?

A 32-year-old female with an acute ischemic stroke was sent for an urgent angiography. Below is the image captured from this study. What is the likely etiology of the patient’s acute ischemic stroke?

A 30-year-old male presents to the emergency room with weakness in his bilateral lower extremities. On arrival, he was hypertensive and bradycardic. 2/5 strength is appreciated in his bilateral lower extremities. A loss of pinprick sensation is also appreciated from his lower extremities, but proprioception and vibratory sensation are intact. These findings are most likely secondary to a lesion of which of the following blood vessels?

Which of the following findings is depicted in the catheter angiogram shown?

A 30-year-old woman presents to the clinic with severe headaches requesting treatment because she “can’t live with this pain”. Episodes are left-sided, occur multiple times a day, and last about 20 minutes each. During episodes, she will also have eye tearing and rhinorrhea. What is the correct diagnosis?

A 55-year-old male cigarette smoker with a past medical history of hypertension and medication non-compliance presents to the emergency room with an excruciating headache and altered mentation. An MRI of the brain is completed and provided below (T2 sequence). Which of the following is the most likely diagnosis?

A 25-year-old female presents to the clinic with headaches for a year that occur two to three times a month. The pain usually occurs on one side and is associated with nausea and light and sound sensitivity. During these episodes, she is unable to go to work. Over-the-counter anti-inflammatories are ineffective. Physical exam and vitals are normal. Which therapy is the most appropriate next option in treatment?

Which of the following is the mechanism of action of aspirin?

Which of the following identifies the vein of Galen?

Identify the lesion below.

A 12-year-old boy with a past medical history of sickle cell disease was admitted to the emergency room in a pain crisis. While being treated with morphine the patient developed acute left arm/leg weakness and numbness. Which of the following is the most likely etiology for the patient’s new neurologic symptoms?

A 90-year-old woman presents to the emergency room with an acute change in mental status. On examination, she is alert but is not answering questions or following commands. Speech is fluent, but not interpretable. Comprehension is severely impaired. Interestingly she was able to repeat full sentences without much difficulty. Which of the following is the most likely territory of ischemic damage?

Which of the following cranial nerve(s) transverses through the structure (blue arrow) shown below?

All of the following medications have Level A or B evidence in migraine prophylaxis except:

A 29-year-old female taking oral contraceptive pills (OCPs), but with no other known medical history, presents for a 3-week course of progressive headache. Given her risk factors, the following imaging study is performed. An occlusion within which of the following structures is seen?

A 30-year-old woman presents to the clinic with severe headaches requesting treatment because she “can’t live with this pain”. Episodes are left-sided, occur multiple times a day, and last about 20 minutes each. During episodes, she will also have eye tearing and rhinorrhea. What is the appropriate therapy?

Which of the following identifies the sigmoid sinus?

Which of the following transverses through the structure (blue arrow) shown below?

A 19-year-old woman was brought to the emergency department after a rollover motor vehicle accident. On arrival, she was intubated and sedated for respiratory failure secondary to pneumothorax. Examination revealed intact brain stem reflexes and decreased spontaneous movement of the left side of her body. Her axial head CT scan is shown below. What is the most likely diagnosis?

An overweight 24-year-old woman complains of neck stiffness, daily headaches, and blurred vision. She has disc edema on fundoscopic exam and slit-like ventricles on MRI brain. A spinal tap was performed and confirmed the diagnosis. Which of the following is the first-line therapy?

Oculomotor nerve palsy is most likely to be seen secondary to an aneurysm in which of the following arteries?

What is the pathophysiology of the lesion provided below?

The trochlear nucleus sends nerve fibers to which of the following muscles?

A 72 y.o. female presents to the clinic with complaints of decreased interest in eating, and has lost weight. She states foods have an unusual taste and are not appealing. On detailed examination, she is found to have normal extraocular movements, normal facial muscle symmetry, and normal facial sensation and swallowing. On further detailed examination, she has a loss of taste sensation in the right anterior two-thirds of her tongue. Of the following, which is the most likely area of injury?

A blood clot in which artery explains the findings below?

Which answer correctly identifies all of the cranial nerve(s) that transverse through the structure (blue arrow) shown below?

A 40-year-old woman of Chinese descent has a cerebral angiogram performed after experiencing recurrent ischemic strokes over the past 5 years. This image is most consistent with which neurological disease?

A 78-year-old male with no past medical history presents to the ED with left-sided hemiparesis and slurred speech at 9 AM. She is unable to provide a clear clinical history. She was noted to be found at 7:30 AM in bed with the above-stated symptoms. Her husband states that the patient went to bed at 10:00 PM the previous night without any symptoms. CT head shows no blood or hypodensities, and CTA head/neck reveals a right MCA occlusion. Her NIHSS is 17. Which of the following treatment options is the most appropriate next step based on the available data?

A 65-year-old woman with a history of a known right posterior communicating artery aneurysm comes to the emergency department with focal neurological symptoms. Brain MRI shows interval enlargement of the aneurysm. Which of the following clinical symptoms is most likely?

Which of the following is not typically treated with indomethacin?

A 59-year-old man with HTN, T2D, and peripheral vascular disease presents with sudden complete loss of vision in the left eye, which resolved after about 20 minutes. He denies any other symptoms. Which of the following vessels was most likely obstructed?

An 82-year-old female patient with a history of atrial fibrillation is brought to the emergency department after being found down at home. She is unable to move her extremities, although she is able to blink and move her eyes vertically. Occlusion of which artery/arteries is the most likely cause of her symptoms?

Which of the following is the reversal agent for dabigatran?

A 67-year-old male with a past medical history of hypertension and diabetes presents with a 5-day history of facial paralysis and an ear rash. The patient states he returned from a 4-day backpacking trip in the Adirondacks 2 weeks ago in upstate New York where he engaged in hiking and freshwater swimming. His temperature is 36.9 °C (98.5°F), pulse is 72/min, and blood pressure is 131/78. Examination reveals an erythematous vesicular rash in the left auditory canal and pinna and drooping of the left face, forehead, and eyelid. A Weber test lateralizes to the right ear and a Rinne test shows air conduction greater than bone conduction in both ears. What is the most likely diagnosis?

A 29-year-old man with a 10-pack-year smoking history comes into the clinic with a severe headache. The pain surrounds his right eye and is associated with a runny nose, excessive tearing, and a “droopy eyelid.” He describes the pain as stabbing that usually lasts about 30 minutes and occurs every day after he eats dinner. What is the most likely diagnosis?

The MR angiogram shown below demonstrates which of the following?